NCLEX Hurst Resources Notes

What is required for high-alert medications?

What are the top 5 high-alert medications and their routes of administration?

An independent double-check is required for high-alert medications—Another licensed nurse will perform a second check to identify the medication, dose, and route to be administered

1. Insulin – subcutaneous and IV

2. Opiates and Narcotics – IV, transdermal, oral

3. Injectable Potassium Chloride or Phosphate Concentrate

4. Intravenous Anticoagulants (Heparin)

5. Sodium Chloride Solutions above 0.9% concentration

1. What can be used in conjunction with the administration of blood and blood products?

2. What do all blood products require?

3. What should be completed prior to blood product administration?

4. What verifications must be made before administration?

1. Only NS may be used in conjunction with administering blood and blood products

2. All blood products require: A filter

3. Set of baseline VS b/f administering the blood + each client must have a type and screen and crossmatch in the lab prior to obtaining a blood product (each type and screen is only good for 72 hr)

4. A designated person in the blood bank verifies with the RN, and the RN verifies with another RN at the bedside.

The following verifications must be made:

• The client’s name, date of birth, blood bank number, unit number, expiration date of unit of blood or blood product, blood type and group, primary healthcare provider’s prescription

1. How quickly should an infusion of blood be started after receiving it from the blood bank?

2. How quickly must blood products be completed?

1. W/in 30 minutes of receiving the blood from the blood bank

2. All blood from each unit must be completed within a 4 hour time frame. If the unit of blood is not completed in a 4 hour time frame the blood must be discarded

During what time period of a blood product administration is a patient most likely to have a transfusion reaction?

List s/s of a transfusion reaction

• Transfusion reaction is most likely to occur w/in the 1st 15 minutes of the infusion, so the client needs to be observed closely, especially for the 1st 15 minutes—if no reaction is observed in the 1st 15 minutes, the infusion rate may be increased

S/s:

1. Chest pain

2. Hives or skin rash

3. Hypotension/Hypertension

4. Fever

5. Chills

6. Anxiety

7. Wheezing

8. Headache or muscle pain with fever

9. Flushing

10. Back pain

11. Dizziness

12. Itching

13. Urticaria

14. Tachycardia

15. Tachypnea

16. Dyspnea

17. GI symptoms: nausea and vomiting

If an adverse reaction to a blood transfusion occurs, as the nurse you should:

1. Discontinue the transfusion IMMEDIATELY

2. Remove blood and blood tubing set.

3. Check your facility’s policies and procedure manual. You may have to return the blood and tubing to the blood bank

4. Start normal saline with new primed tubing at keep vein open rate

5. Check and document vital signs. Stay with client

6. Notify primary healthcare provider and monitor client closely for anaphylaxis

7. Notify lab/ blood bank of transfusion reaction

For the analgesic/antipyretic: Acetaminophen

1. Common uses?

2. Contraindications?

3. Routes?

4. Interactions?

5. MOA?

6. Advantages/Disadvantages?

7. Side effects?

8. Adverse Effects?

9. Nursing Interventions?

10. Client Education?

For the pharmacologic class: NSAIDs

1. List common agents

2. Common uses?

3. Contraindications?

4. Routes?

5. Interactions?

6. MOA?

7. Advantages/Disadvantages?

8. Side effects?

9. Adverse Effects?

10. Nursing Interventions?

11. Client Education?

For the pharmacologic class: Opioids

1. List common agents

2. Common uses?

3. Contraindications?

4. Routes?

5. Interactions?

6. MOA?

7. Advantages/Disadvantages?

8. Side effects?

9. Adverse Effects?

10. Nursing Interventions?

11. Client Education?

For the pharmacologic class: Salicylate

1. List common agents

2. Common uses?

3. Contraindications?

4. Routes?

5. Interactions?

6. MOA?

7. Advantages/Disadvantages?

8. Side effects?

9. Adverse Effects?

10. Nursing Interventions?

11. Client Education?

For the medication class: Aminoglycosides (antibiotic)

1. List common agents

2. Common uses?

3. Contraindications?

4. Routes?

5. Interactions?

6. MOA?

7. Advantages/Disadvantages?

8. Side effects?

9. Adverse Effects?

10. Nursing Interventions?

11. Client Education?

For the medication class: Antibacterial/Antiprotozoal

1. List common agent(s)

2. Common uses?

3. Contraindications?

4. Routes?

5. Interactions?

6. MOA?

7. Advantages/Disadvantages?

8. Side effects?

9. Adverse Effects?

10. Nursing Interventions?

11. Client Education?

For the medication: Antibiotics—Vancomycin

1. Common uses?

2. Contraindications?

3. Routes?

4. Interactions?

5. MOA?

6. Advantages/Disadvantages?

7. Side effects?

8. Adverse Effects?

9. Nursing Interventions?

10. Client Education?

For the medication class: Anthelminthics

1. List common agent(s)

2. Common uses?

3. Contraindications?

4. Routes?

5. Interactions?

6. MOA?

7. Advantages/Disadvantages?

8. Side effects?

9. Adverse Effects?

10. Nursing Interventions?

11. Client Education?

For the medication class: Antivirals—HIV

1. List common agent(s)

2. Common uses?

3. Contraindications?

4. Routes?

5. Interactions?

6. MOA?

7. Advantages/Disadvantages?

8. Side effects?

9. Adverse Effects?

10. Nursing Interventions?

11. Client Education?

For the medication class: Broad Spectrum Antibiotics—Clindamycin

1. Common uses?

2. Contraindications?

3. Routes?

4. Interactions?

5. MOA?

6. Advantages/Disadvantages?

7. Side effects?

8. Adverse Effects?

9. Nursing Interventions?

10. Client Education?

For the medication class: Cephalosporins—4 Generations of them

1. List common agent(s) for each generation

2. Common uses?

3. Contraindications?

4. Routes?

5. Interactions?

6. MOA?

7. Advantages/Disadvantages?

8. Side effects?

9. Adverse Effects?

10. Nursing Interventions?

11. Client Education?

For the medication class: Fluoroquinolones

1. List common agent(s)

2. Common uses?

3. Contraindications?

4. Routes?

5. Interactions?

6. MOA?

7. Advantages/Disadvantages?

8. Side effects?

9. Adverse Effects?

10. Nursing Interventions?

11. Client Education?

For the medication class: Macrolides

1. List common agent(s)

2. Common uses?

3. Contraindications?

4. Routes?

5. Interactions?

6. MOA?

7. Advantages/Disadvantages?

8. Side effects?

9. Adverse Effects?

10. Nursing Interventions?

11. Client Education?

For the medication class: Non-HIV Antivirals

1. List common agent(s)

2. Common uses?

3. Contraindications?

4. Routes?

5. Interactions?

6. MOA?

7. Advantages/Disadvantages?

8. Side effects?

9. Adverse Effects?

10. Nursing Interventions?

11. Client Education?

For the medication class: Penicillins

1. List common agent(s)

2. Common uses?

3. Contraindications?

4. Routes?

5. Interactions?

6. MOA?

7. Advantages/Disadvantages?

8. Side effects?

9. Adverse Effects?

10. Nursing Interventions?

11. Client Education?

For the medication class: Sulfonamides

1. List common agent(s)

2. Common uses?

3. Contraindications?

4. Routes?

5. Interactions?

6. MOA?

7. Advantages/Disadvantages?

8. Side effects?

9. Adverse Effects?

10. Nursing Interventions?

11. Client Education?

For the medication class: Tetracyclines

1. List common agent(s)

2. Common uses?

3. Contraindications?

4. Routes?

5. Interactions?

6. MOA?

7. Advantages/Disadvantages?

8. Side effects?

9. Adverse Effects?

10. Nursing Interventions?

11. Client Education?

For the medication class: Alkylating Agents (Chemotherapy)

1. List common agent(s)

2. Common uses?

3. Contraindications?

4. Routes?

5. Interactions?

6. MOA?

7. Advantages/Disadvantages?

8. Side effects?

9. Adverse Effects?

10. Nursing Interventions?

11. Client Education?

What isolation/precautions are necessary for Amebiasis(Entamoeba histolytica) Dysentery

Infective material?

Duration of isolation?

What isolation/precautions are necessary for Bronchiolitis?

Infective material?

Duration of isolation?

What isolation/precautions are necessary for Varicella (chicken pox)

Infective material?

Duration of isolation?

Describe the precautions necessary

What isolation/precautions are necessary for Clostridium dificile enterocolitis

Infective material?

Duration of isolation?

What isolation/precautions are necessary for the “common cold”

Infective material?

Duration of isolation?

What isolation/precautions are necessary for conjunctivitis (viral or bacterial)

Infective material?

Duration of isolation?

What isolation/precautions are necessary for COVID-19

Infective material?

Duration of isolation?

Describe the additional precautions/recommendations for COVID-19

What isolation/precautions are necessary for diphtheria (cutaneous)

Infective material?

Duration of isolation?

What isolation/precautions are necessary for diphtheria (pharyngeal)

Infective material?

Duration of isolation?

What isolation/precautions are necessary for Ebola

Infective material?

Duration of isolation?

Describe the additional precautions/recommendations for Ebola

What isolation/precautions are necessary for Epiglottitis

Infective material?

Duration of isolation?

What is the common cause?

What isolation/precautions are necessary for Fifth’s Disease/Erythema Infectiosum (Parvovirus B19)

Infective material?

Duration of isolation?

What isolation/precautions are necessary for Rubella

Infective material?

Duration of isolation?

Describe the additional precautions/recommendations for Rubella

What isolation/precautions are necessary for Meningitis

Infective material?

Duration of isolation?

What isolation/precautions are necessary for Pneumonia

Infective material?

Duration of isolation?

What isolation/precautions are necessary for Herpes zoster (Shingles)

Infective material?

Duration of isolation?

What isolation/precautions are necessary for Measles (rubeola, red measles)

Infective material?

Duration of isolation?

Additional comments/recommendations?

What isolation/precautions are necessary for MDROs (MRSA and VRE)

Infective material?

Duration of isolation?

Additional comments/recommendations?

What isolation/precautions are necessary for Scabies (same for pediculosis)

Infective material?

Duration of isolation?

What isolation/precautions are necessary for Tuberculosis

Infective material?

Duration of isolation?

Additional comments/recommendations?

What isolation/precautions are necessary for Pertussis (whooping cough)

Infective material?

Duration of isolation?

Additional comments/recommendations?

What isolation/precautions are necessary for Zika?

Infective material?

Duration of isolation?

Additional comments/recommendations?

1. What do standard precautions apply to, and when should they be used?

2. List what is included in standard precautions

Standard Precautions apply to 1) blood; 2) all body fluids, secretions, and excretions except sweat, regardless of whether or not they contain visible blood; 3) nonintact skin; and 4) mucous membranes.

• Use Standard Precautions, or the equivalent, for the care of all clients

Included in Standard Precautions:

1. Handwashing

2. PPE—Gloves, Gown, Mask/eye protection/face shield,

3. Client-Care Equipment—properly cleaned reusable equipment before it is reused; single-use items discarded properly; prevent transfer of microorganisms from equipment to people

4. Linens—handle/transport/process soiled linen w/o transfer of microorganisms (to other people/environments)

5. Sharps Safety—needles/sharps placed directly into puncture-resistant containers; do not recap used needles or use two hand technique; sharps w/ built-in safety features used when available

6. Respiratory hygiene/cough etiquette—covering coughs and sneezes, wearing masks, and throwing away tissues

What is the correct order to don PPE?

Don PPE: Mnemonic = Don is a good man, and Good Men Get Got

1. Gown

2. Mask or respirator (N95)

3. Goggles or face shield

4. Gloves

What is the correct order to doff PPE?

—Doffing is in alphabetical order

1. Gloves

2. Goggles

3. Gown

4. Mask

What are contact precautions designed to do?

How are microorganisms transmitted in contact precautions?

List what is included in contact precautions

Contact Precautions are designed to reduce the risk of transmission of microorganisms by direct or indirect contact

Transmission:

• Direct-contact transmission involves skin-to-skin contact and physical transfer of microorganisms to a susceptible host from an infected or colonized person, such as occurs when personnel turn clients, bathe clients, or perform other client-care activities that require physical contact

• Indirect-contact transmission involves contact of a susceptible host with a contaminated intermediate object, usually inanimate, in the client’s environment.

Included in Contact Precautions

A. Client Placement

1. Place the client in a private room

2. When a private room is not available, place the client in a room with a client(s) who has active infection with the same microorganism but with no other infection

B. PPE and Handwashing

1. Wear gloves and gown

2. Remove gloves before leaving the client’s room and wash hands immediately with an antimicrobial agent or a waterless antiseptic agent. For a client with C. diff do not use an alcohol-based, hand rub because it is not effective on C. diff use soap and water

C. Client Transport

1. Limit the movement and transport of the client from the room to essential purposes only

2. If the client is transported out of the room, ensure that precautions are maintained to minimize the risk of transmission of microorganisms to other clients and contamination of environmental surfaces or equipment.

In what patient’s should airborne precautions be used?

List what is included in airborne precautions

Use airborne precautions in patient’s:

For clients known or suspected to be infected with microorganisms transmitted by airborne droplet nuclei or evaporated droplets containing microorganisms that remain suspended in the air and that can be dispersed widely by air currents within a room or over a long distance

A. Client Placement

1. Place the client in an airborne infection isolation room (AIIR), which is a

private room that has:

• Monitored negative air pressure in relation to the surrounding areas 6 to 12 air changes per hour

• Appropriate discharge of air outdoors or monitored high-efficiency filtration of room air before the air is circulated to other areas in the hospital.

2. Keep the room door closed and the client in the room

3. Client should have a private room

4. When a private room is not available, place the client in a room with a client who has active infection with the same microorganism but with no other infection

B. Respiratory Protection

1. Wear respiratory protection (N95 respirator) when entering the room of a client with known or suspected infectious pulmonary tuberculosis

Susceptible persons should not enter the room of clients known or suspected to have measles (rubeola) or varicella (chickenpox) if other immune caregivers are available. If they must enter, they should wear a respirator mask.

C. Client Transport

1. Limit the movement and transport of the client from the room to essential purposes only

2. If transport or movement is necessary, place a surgical mask on the client.

How is disease transmitted in patients with droplet precautions?

Transmission of Disease Via Droplets

• Droplet transmission involves contact of the conjunctivae or the mucous membranes of the nose or mouth of a susceptible person.

• Droplets are generated from the source person primarily during coughing, sneezing, or talking and during the performance of certain procedures such as suctioning and bronchoscopy.

• Transmission via large-particle droplets requires close contact between source and recipient persons, because droplets do not remain suspended in the air and generally travel only short distances, usually 3 ft or less, through the air

A. Client Placement

1. Place the client in a private room

2. When a private room is not available, place the client in a room with a client(s) who has active infection with the same microorganism but with no other infection

B. Mask

1. In addition to wearing a mask as outlined under Standard Precautions, wear a mask when working within 3 ft of the client. (Logistically, some hospitals may want to implement the wearing of a mask to enter the room.)

C. Client Transport

1. Limit the movement and transport of the client from the room to essential purposes only

2. If transport or movement is necessary, place a surgical mask on the client.

What type of isolation precaution will the client be on with the following diseases?

1. Human Immunodeficiency Virus (HIV)

2. Multidrug- resistant organisms (MDROs) (e.g., MRSA, VRE, VISA/VRSA,

ESBLs, resistant s. pneumoniae)

3. Candidiasis (Thrush)

4. Varicella Zoster (Chicken pox)

5. Clostridium Difficile Enterocolitis (C. Diff)

6. Infectious Mononucleosis (Mono)

7. Rubella (German Measles)

8. Meningococcal Meningitis

9. Impetigo

10. Seasonal Influenza

11. Rubeola (Measles)

12. Tuberculosis (TB) with pulmonary involvement

13. Infectious Parotitis (Mumps)

14. Rotavirus

15. Pertussis (Whooping Cough)

16. Tetanus

17. Escherichia Coli Gastroenteritis (E coli)

18. Herpes zoster (Shingles) Localized

19. Herpes zoster (Shingles) Disseminated disease

20. Respiratory Syncytial Virus (RSV)

21. Lice (head)

22. Lyme disease

23. Coronavirus/COVID-19

1. Standard

2. Standard/ Contact*

3. Standard

4. Airborne and contact

5. Contact

6. Standard

7. Droplet

8. Droplet for 24 hours

9. Contact for 24 hours

10. Droplet

11. Airborne

12. Airborne

13. Droplet for 9 days

14. Contact

15. Droplet

16. Standard-not transmitted person to person

17. Standard-contact for diapered incontinent persons

18. Standard-localized

19. Airborne and contact

20. Contact

21. Contact-isolation up to 24 hours

22. Standard-not transmitted person to person

23. Droplet

List the five rights of delegation, and what is required of the nurse for each right of delegation

(1) Right task

• The task must be within the capabilities of the auxiliary nursing staff as defined by federal and state statutes (Nurse Practice Act), organizational policies and procedures; job descriptions and accreditation guidelines

• Assess each client before delegating. Ensure there is match between the client’s needs and the skills, abilities and experience of the Auxiliary Nursing Staff

• Consider the client’s condition, the personnel’s capabilities, the complexity of the task, and how much supervision will be required

• Assistive personnel should not be assigned duties requiring ongoing assessment, evaluation or decision making.

(2) Right circumstances

• The care setting should be taken into consideration

—For example, the role of the LPN may differ in an acute care setting in comparison to their role in a long

term care setting

• Client stability as well as the desired client outcomes should also be taken into

consideration

(3) Right person

• Know your facility’s competency standards

• Know the job descriptions of co-workers

• Has the personnel been trained on the task?

• Identify personal strengths and weaknesses of Auxiliary Nursing Staff

(4) Right direction and communication

• The Registered Nurse is responsible for providing clear, concise, correct, and complete communication to Auxiliary Nursing Personnel at the time of delegation as well as providing continued direction on an ongoing basis

• Communicate clearly about the delegated task

• Be specific about how and when he/she should report back to you

• Make sure the personnel understands what is expected, and do not hesitate to ask them if they know how to perform the task

(5) Right supervision and evaluation

• You cannot just merely assign the task. You must guide, supervise, and evaluate the carrying out of the delegated task

• You must ensure the work meets your expectations. If it does not, you must step in

• Give credit and praise for accomplishments. Do not hesitate to offer observations and share concerns

• You should give the personnel feedback and ask for theirs

• Encourage input on how to resolve care issues and reach agreement on future course of action

• You must evaluate the client’s outcome and the results of the task to ensure the desired outcome is achieved

REMEMBER: You may delegate a task, but the responsibility remains with you,

the RN!!

The Nursing Process and clinical judgment cannot be delegated by the Registered Nurse to Nursing Assistive Personnel

What can/can’t a PN (LPN) do?

Classify the following as stable or unstable:

Post-op client being discharged with no family New admission

Stable

Classify the following as stable or unstable:

New admission

Unstable

Classify the following as stable or unstable:

Client with COPD, stable vitals, and uses O2

Stable

Classify the following as stable or unstable:

Neuro checks suddenly change

Unstable

Classify the following as stable or unstable:

Diabetic with a wound, stable blood sugar, taking medications as ordered

Stable

Classify the following as stable or unstable:

Diabetic with low blood sugar

Unstable

Classify the following as stable or unstable:

Client with neurological problems, stable vital signs, no change in LOC/neuro checks

Stable

Classify the following as stable or unstable:

Client returning from an invasive procedure

Unstable

Classify the following as stable or unstable:

Client with dehydration, stable electrolytes, appropriate urine output, and improving hydration

status

Stable

Classify the following as stable or unstable:

Client with acid-base imbalance and respiratory distress with unstable vital signs

Unstable

Classify the following as stable or unstable:

Client with chronic hypertension, history of angina controlled with meds & lives alone

Stable

Classify the following as stable or unstable:

Client with syncope and chest pain

Unstable

Classify the following as stable or unstable:

Client with HIV+, medication compliance and works full time

Stable

Classify the following as stable or unstable:

Client with recent 2nd & 3rd degree burns

Unstable

Classify the following as stable or unstable:

Client with history of cancer in remission and young children in home

Stable

Classify the following as stable or unstable:

Client with infectious diseases - new onset

Unstable

Classify the following as stable or unstable:

Client with history of stroke, paresthesias, and rehab equipment

Stable

Classify the following as stable or unstable:

Client with multiple IV fluids & meds, plus lab & vital sign changes

Unstable

What is asthma?

What is happening in the airway of a person with asthma?

How is Asthma different from RSV?

Asthma: Chronic inflammatory disorder of the airway

What is happening in the person’s airway?

- Edema

- Inflammation

- Tenacious secretions,

- Smooth muscle spasms (wheezing and bronchospasm)

- Decreased expiratory airflow

How is asthma different from RSV?

• Asthma is inflammation and bronchoconstriction of the airways, resulting in an obstruction

• Also, asthma is not a virus

List causes/triggers of asthma

1. Allergy

2. Environmental allergens (dust mites and roaches)/Dust

3. Smoke (any form)

4. Medication

5. Pets

6. Exercise

7. Change in the weather (cold air)

8. Strong emotions

List s/s of asthma

1. Recurrent episodes of wheezing

2. Can’t catch their breath, dyspnea

3. Cough

4. Fatigue

5. Chest tightness/pain

6. Retraction in infants

7. Hyperresonance of chest with percussion

8. Coarse and loud breath sounds

9. Repeated episodes = barrel chest

10. Symptoms usually worse at night.

List s/s of an acute asthma attack

What will occur as the asthma attack becomes more severe?

Symptoms of acute asthma attack:

1. Child may start to report itching in the front of their neck or their upper back

2. Will start out feeling restless and report a headache

3. Will be tired, irritable, with a hacking non – productive cough

4. Their chest begins to tighten as secretions increase and their cough becomes rattling and productive (clear frothy sputum)

As the attack becomes more severe:

1. The child will try to breathe more deeply

2. The expiratory phase will be prolonged with audible wheezing

3. Appearance will be pale and may become cyanotic

4. Restlessness increases

5. Anxious expression

6. Sweating

7. Younger children may assume the tripod sitting position, whereas the older child will sit up with shoulders hunched over with hands on legs or bed to facilitate use of accessory muscles

How is asthma diagnosed?

Difficult to diagnose asthma in infants (many conditions can cause wheezing and retractions)

1. Chronic cough with no signs of infection and/or diffuse wheezing during expiration is sufficient to diagnose asthma

2. Pulmonary function test: Helps to determine the presence and degree of lung disease and response to respiratory therapy

3. Spirometry function test reliable for children older than 5 or 6 years

4. Peak expiratory flow rate (PEFR): Max airflow that can be forcefully exhaled in one second.

• Each child’s PEFR based on age, race, height and gender

List the possible treatments for asthma

1. Chest Physiotherapy

2. Percussion, vibration, squeezing the chest and breathing exercises (blowing bubbles = pursed-lip breathing)

3. Do not administer this therapy during an acute episode

4. Monitor O2 sat

5. Allergy shots (Allergy proof the house) **Only administer allergy shots if emergency equipment is available in case of anaphylactic shock

6. Small frequent meals – to prevent abdominal distention and help prevent the diaphragm from expanding

7. Encourage fluids to thin secretions, but no extremely cold fluids be cause cold can induce a bronchospasm

8. Evaluate participation in exercise activities on an individual basis

9. Humidified O2

10. Respiratory medications

• Bronchodilators (beta adrenergic agonists)-SABAs (Albuterol, Terbutaline), LABAs (Salmeterol)

• Bronchodilators (Antileukotriene/Leukotriene Receptor Antagonists)—Montelukast, Zafirlukast

How is live attenuated influenza vaccine given?

Live attenuated influenza vaccine = FluMist

—given via the intranasal route

How is rotavirus given?

Orally

When administering SubQ injections:

1. What gauge needle should you use?

2. What needle length should be used for infants?

3. What needle length should be used for children 12 months and older?

1. Use a 23-25 gauge needle

2. Needle length for infants (1-12 months) is 5/8”

3. Children 12 months and older 5/8” to 1 inch

When giving IM injections using a 22-25G needle:

1. What is the needle length used in the first 28 days of life?

2. What about infants (2-12 months) in the anterior thigh?

3. What about Toddlers/Children in the anterolateral thigh, and the deltoid?

1. 5/8”

2. 1”

3. 1-1 ¼” for anterolateral thigh and a 5/8” needle for the deltoid

What is a ventricular septal defect (VSD)?

S/s?

Tx?

Is this a cyanotic or acyanotic defect?

This is when there is an opening between the left and right ventricle (in

the septum)

This increases the volume on the right side of the heart. The right side

is having to pump harder so this can lead to right sided heart failure.

Many close spontaneously during the first year of life, but if not will have

surgical repair.

Signs and Symptoms:

- Signs of heart failure

- Murmur

What is coarctation of aorta?

S/s?

Tx?

Is this a cyanotic or acyanotic defect?

The aorta has a narrowing (pretend there is a tourniquet tied around the

aorta). This makes it harder for the LV to pump so the client may wind up

with left sided heart failure.

Signs and Symptoms:

- Hallmark Sign: There is a BIG difference in the pulses and BP of the

upper and lower extremities. For example, you may have a pediatric

client with an Upper extremity BP = 100/60 and Lower extremity

BP = 70/40

- The upper pressures are much greater than the lower pressures.

Treatment:

- Surgery

- Angioplasty in some

What is the purpose of the ductus arteriosus in normal fetal circulation?

What is patent ductus arteriosus (PDA)?

What does this lead to?

S/s?

Tx?

Is this a cyanotic or acyanotic defect?

Normal fetal circulation: Blood goes Right Atrium….Right Ventricle….

Pulmonary Artery…doesn’t go to lungs….instead when blood leaves PA

it goes straight over to the aorta via the ductus arteriosis. Why does the

blood do this? Because in utero the baby’s lungs are collapsed, and the

baby gets oxygen through the placenta.

This ductus arteriosis is supposed to close when the baby is born and

takes their first breath. When it closes then blood flows from the

Pulmonary Artery to the lungs etc….just like in the adult. But when it

doesn’t……

This leads to increased workload on the left side of the heart and therefore

left sided heart failure.

Some blood is going like it’s supposed to, but some is going over to the right

side because the left side is pushing it to the right.

Signs and Symptoms:

- May be asymptomatic

- May be in heart failure

- They have a machinery - like murmur

Treatment:

- Indomethacin (Indocin®) (prostaglandin inhibitor) will close PDA

- May need surgery to close the ductus

What occurs in transposition of the great vessels?

Is this a cyanotic or acyanotic defect?

S/s?

Tx?

in your cardiac lecture?)

In transposition of the great vessels, the pulmonary artery and the aorta

have swapped places. The aorta is still going to the right side of the heart

and the pulmonary artery is going to the left but they never connect or

cross.

So you wind up with 2 separate sets of circulation going in and out of the

heart. Yes, some blood is getting out to the systemic circulation, or the

client would be dead at birth. Instead, the baby is cyanotic at birth, but

alive. What’s keeping the baby alive?

- Usually there is some other defect that is allowing that baby to get

just enough oxygen to stay alive. (often it is a PDA)

Signs and Symptoms:

- Usually cyanotic at birth

- If not picked up on until older……decreased growth, poor feeding

Treatment:

- Surgery

What does tetralogy of Fallot consist of?

Is this a cyanotic or acyanotic defect?

S/s?

Tx?

Consists of 4 defects:

a. Ventricular Septal Defect (VSD)

b. Pulmonary Artery Stenosis

c. Overriding Aorta

d. Right Ventricular Hypertrophy

Signs and Symptoms:

- Infants may be cyanotic at birth: others may have mild cyanosis that

progressively worsens during first year

- Murmur

- Acute cyanotic or hypoxic spells (blue spells/Tet spells)

*usually seen during crying, after feeding, during bowel movements

*at risk for sudden death, seizures

- Older children: Squatting, nail clubbing, poor growth, exercise

intolerance

Treatment:

- Surgery

What are the early s/s of heart failure in children?

What is included in the treatment of heart failure in children?

• Ongoing Assessment

• Listen to the lungs

• Control room temperature

• Sit them up

• Rest a lot

• Decrease stimuli

• Cool humidified oxygen

• Uninterrupted sleep

• Medications:

1. Digoxin (Lanoxin®) Normal Digoxin Level = 0.8-2.0 ng/mL

2. ACE Inhibitors

3. Furosemide (Lasix)

List instructions regarding the administration of digoxin to a pediatric patient

GIVE DIGOXIN (LANOXIN ®) 1 HOUR BEFORE OR 2 HOURS AFTER FEEDING

• Do Not mix with food or fluid

• If you miss a dose and it is 4 hours past due on the dose, you are

going to hold the dose and give the next dose on time.

• Do not give more if the baby vomits

• If two doses in a row are missed, call the primary healthcare

provider

• ALWAYS check the dose with another nurse

1. What is normal digoxin level?

2. Main s/s of toxicity in a pediatric patient?

3. When should you hold the dose for infants?

4. When should you hold the dose for children?

5. What is common regarding the dose of digoxin for infants?

Normal Digoxin Level = 0.8-2.0 ng/mL

Main signs of toxicity are bradycardia and vomiting

For infants, hold the dose if the pulse is < 110

For children, hold the dose if the pulse is < 70

Infants rarely get more than 1 mL of digoxin (Lanoxin ®) per dose.

Common ACE inhibitors?

What should you watch for regarding ACE inhibitors?

How do they work?

Common Ace Inhibitors: captopril (Capoten®) and enalapril

(Vasotec®)

With Ace Inhibitors, watch for:

1) decreased blood pressure

2) kidney problems

3) a cough

Work by blocking aldosterone

When would furosemide be used to treat a pediatric patient with heart failure?

May be needed to decrease volume (as evidenced by crackles on auscultation, edema, JVD, ect.)

For the pediatric client with heart failure, list nutrition guidelines

• Well rested prior to eating

• Small frequent feedings

• Increase calories

• Good feeding schedule for a heart baby is every 3 hours

• Don’t prolong infant feedings past 30 minutes

• Use a soft nipple with a larger opening, so the baby won’t have to

work so hard

• Breastfed babies may need additional supplements for calories

What are the effects of chronic hypoxia on pediatric patients with heart failure?

• Polycythemia: increased red blood cells

Why does this happen? The body senses that the body is hypoxic

and makes more red blood cells to carry oxygen, but there’s no more

oxygen to carry. So the blood gets really thick.

Keep them hydrated to keep the blood thinned out.

With polycythemia, there are so many RBCs, there’s no room for

platelets.

• Clubbing

*Late sign of chronic hypoxia

• Poor growth and development

• Squatting

What is pneumonia?

List potential causes

S/s?

Tx?

Pneumonia

. Disease marked by inflammation of the lung parenchyma.

A. Causes: can be bacterial, viral, mycotic or aspiration of a foreign

substance.

1. Viral: Common viral causes are RSV, adenovirus or parainfluenza

2. Bacterial: Usual culprit is strep pneumonia.

Children <4 years of age have the greatest % of attacks.

3. Mycotic: or “walking pneumonia” is primarily in adolescents

and is caused by Mycoplasma pneumonia.

4. Aspiration pneumonia: As the name implies, occurs when

something other than air has gotten into the lungs

e.g. peanuts, marshmallows, water, etc.

B. Signs and Symptoms:

1. Fine crackles or rhonchi, with a cough that is either productive

or non-productive

2. Decreased or absent breath sounds over the lung fields.

3. Abdominal distention

4. Back pain

5. Fever that is usually quite high

6. Chest pain

Treatment: (depends on the type of pneumonia)

1. The first priority is always the ABC’s

2. Oxygen

3. Plenty of fluids to keep hydrated

4. If bacterial, then antibiotics are ordered

5. If viral, we generally provide supportive care: hydration,

antipyretics, nebulizer

What age range is considered infancy?

What is the Erikson stage for this age range?

List the basic principles of this growth/development stage

Infancy is birth to 12 months of age: Trust vs Mistrust (Erikson)

Basic Principles:

• This is a time when the primary source of activity is through

the mouth; examples are rooting and sucking reflex, feeding,

and pacifier.

• Repeated use of reflexes develops experiences

• Young infants are totally self-centered; they have little tolerance

for delayed gratification

• At 4-8 months they can perform a desired activity that will produce

a result. Example: secures object by pulling on a string

• Late infancy: develops the concept of object permanenceunderstands

parents are present even if not in line of vision,

works to get toy that is out of reach

• Comprehends simple commands and meaning of words

• Can say bye-bye and blow kisses

• Begins to explore their surroundings

• Infants trust that their needs will be meet (feedings, diaper

changes, comfort, stimulation)

• The trust developed during infancy is the foundation for all

relationships and for the progression of further development

• The single most important element in developing trust is consistency

in caregivers. Infants love routines! So do things like having a

regular feeding schedule, bathe every night then give a bottle and

go to bed.

List assessment guidelines for the assessment of an infant (birth to 12 months of age) in the following areas:

1. Important things to focus on when assessing the infant

2. Weight

3. Fontanels

4. Verbal skills

Important things to focus on when assessing an infant

– Head control: should have no head lag by 4 months

– Pincer grasp: should have established pincer grasp by

11 months of age. Remember up until 1 month of age

hands are closed, grasping at 2-3 months is a reflex.

By 5 months, infants can voluntarily grasp an object.

– Rolling over: should be able to roll over from abdomen

to back at 5 months of age. No your baby isn’t advanced

if they rolled over at 2 months…..it was an ACCIDENT!!

• Weight: gain 5-7oz weekly for first 6 months; at 2 weeks, the

infant should have gained back to their birth weight, then

weight should double around 5 months of age and triple by age 1

• Posterior fontanel closes by 2 months of age anterior fontanel

closes by 18 months of age

• Verbal skills: should be able to imitate sound around 6 months,

by 8 months combines syllables like dada but doesn’t know the

meaning, 9 months responds to simple commands, comprehends

no-no, 10 months says dada and mama with meaning attached,

12 months says 3-5 words

List the important developmental milestones of infancy (birth to 12 months)

Developmental Milestones

• Some important developmental milestones to remember:

– By 2 months can try to pull up with some head control

– By 7 months should bear weight on feet, can sit with support,

transfers object from one hand to the other

– By 8 months can move from sitting to kneeling, sits

without support

– By 9 months can stand holding onto furniture, creeps on hands

and knees

– 9-10 months takes deliberate steps

– By 12 months walks with 1 hand held, can sit down from standing

position without help

What are signs that an infant may be in pain?

– Facial grimaces

– Postural changes, thrashing

– Crying loud and excessively

– Inconsolable