important stuff to know

erikson stage for infant

trust vs mistrust. 0-18mo

erikson stage for toddler

autonomy vs shame and doubt, 18mo - 3yr

eriksone stage for preschool

initative vs guild 3-5

erikson stage for school age

industry vs inferority, 5-13yr

erikson stage for adolescent

identity vs role confusion, 13-21yr

chadwick sign

bluish or purple discoloration of th vulva or cervix

goodell sign

softening of the cervix

hegar sign

sofetning of the lower segment of the uterus

VEAL CHOP

variable - cord compression

early decel - head compression

acceleration - okay

late decel - placental insufficiency

what are the interventions for VEAL CHOP

varaible, cord compression, change the position of the mom (o2, IVF, stop pitocin)

early, head compression → head check, vag exam (reassuring though)

accel, okay → observe

late, placental insufficnecy → perfusion (turn mom to left side, O2, IVF, stop pitocin, notify provider and prepare for possible c section

what does a boggy uterus mean for after birth

it means uterine atony, the intervention is fundal massage, no need to tell provider or to give oxtocin

what to do if mom has mastitis

a common, benign, soft tissue swelling or edema on a newborn's scalp

nursing interventinos: do not stop breastfeeding, encourage feeding on affected side, wnat to empty breast completely

• warm compress on breast and gentle massage towards nipple before feeding

• after the feeding, cold compress

what is caput succedaneum

cross sutures

which is bad, caput succedaneum or cephalohematoma

caput

contractions should be how many mins apart and how long should the duration be

90 sec and 2 min2-5 mins apart with < 90s

what is the dilation, contraction, duration, intensity of LATENT phase

0-4cm, 5-30 mins, 15-30s, mild

what is the dilation, contraction, duration, intensity of ACTIVE phase

5-7cm, 3-5min, 30-60s, intensity moderate

what is the dilation, contraction, duration, intensity of PROGRESSIVE phase

8-10cm, 2-3min, 60-90s, strong

cancer classic warning signs

change in bowel and bladder habits

a sore that does not heal

unusual bleeding or discharge

thickening or lump on breast/elsewhere

indigestion or diff swalloing

obvious change in a wart or mole

nagging cough or hoarseness

for in infant, what are the needs and focus

safety w/ mother or caregiver

for a toddler, what are the needs and focus

independent from parents

for a preschooler what are the needs and focus

powerful within family & exploring

for a school age, what are the needs and focus

good w/ neighbors, classroom and friends

for adolsence, what are the needs and focus

socializing and fit into peer groups

what is considered a stable pt

chronic

post op > 12 hours

unchanged assessments

ready for discharge

s/s common for dx

adm for > 24 hours

what is considered a unstable pt

acute

post op <12 hours

changed assessment

newly dx

s/s uncommon for dx

unexpected

RF for colon cancer

65+ age, IBD, obesity, smoking, low fiber diet

RF for ovarian cancer

65+, genetic, obesity, endometreis

RF for prostate cancer

50+, genetics, obesity

what is an indication of CSF leak

halo or ring will occur when CSF is mixed with blood, seen on like gauze

common s/s for ARDS

refractory hypoxemia - when O2 level is low, despite high amount of supplemental O2

• severe V/Q mismatch, some alveoli are poorly ventilated but still perfused

gastric ulcer versus duodenal ulcer

gastric pain is immedaitely after eating or during

duodenal , relief of pain after eating 2-3 hours after

bladder cancer common s/s

painless hematuria

common s/s for pernicious anemia

beefy (red) smooth tonguefe

fetal alcohol syndrome s/s

thin upper lip & smooth philitrum

neurogenic shock s/s

dec HR and DEC BP

what can people wit celiac disease NOT eat

barely, rye, oat, wheat → BROW

AKI diet/renal diet

dec protein, inc calories

copd diet

small frequent meals, inc cal and fat

pancreatitis diet

small freq meals, dec fat

galbladder issues = less fat, CHOLE

disorders that need more fluids

cystic fibrosis, kidney stones, sickle cell, ostomy

what foods are odorous and form gas that should be avoided for ostomy

onion, broccolili, spinach

if pt has gout, what food should be avoided

high in purine, seafood, shellfish, organ meats

diet for ulcerative colitis

low fiber

what is ulcerative colitis

only the colon, continuous inflammation

• s.s: bloody diarrhea, mcusu in stool, lower abd pain, risk of colon cancer

delegation tip

only rn can do initial teaching and the discharge edu.

the rn should care for unstable pt and the lpn can take care of stable pt

when should nsaids be contra

CV history, stroke, MI, CAD

NC for pheochromocytoma

do not palpate these pt abdomen, it can cause hypertensive crisis

meningitis NC

is suspected to have meningitis, place them on droplet precaution right away

barium enema

purpose: visualize the colon with contrast

contraindication: acute diverticulitis, risk of rupture

SE: abd cramp, urge to defecate

pre op teaching: clear liquid diet day before, NPO 8 hours

post op: expect chalky white stool, take laxative to prevent fecal impaction

drink lots of fluid to promote hydrate and eat fiber diet

chest physio

definition: technique of airway clearance

indications: Cystic fibrosis

manual percussion: cupped hand into chest, have pt cough and deep breath

what are indications for chest tuibe

drain fluid, blood and air

what is the OU that you should report, and what are the changes you should seek

>70, look at VS for indicatations of bleeding or hemorrhage

manifestation of air leak in chest tube & what is the intervention

cont bubbling in water seal chamber

• start at chest tube and move down tubing to locate leak, tighten it and replace drainage system

interventino for no tidaling in water seal chamber

check for kinks in tubing or check for breath sounds, are the lungs expanding???

intervention for no bubbling in suction chamber

verify if tubing is attached

verify that water is filled to prescrobed lvel

check wall suction

chest tube out of system

put the end in a bottle of sterile water

chest tube out of pt

cover site with gloved hand

• 3 sided tape on the exertion of tube

• 4 sides can cause pneumothorax

• call HCP and anticpate insertion of new chest tube

• stay with client and assess lung sounds and monitor VS

how often change ostomy bag

5-10 days

nursing consideratinos for ostomy

inc fluid intake

avoid moisturizing soap!!!!!, hard for bag to stick

use stoma powder for raw skin

retroinduce food one at a time

burp the bag

cont bladder irrigation

3 way catheter used to cont infused the solution by grav

rate is determined by how much to keep cath patent

indications: prescribed following transurethral resection of the prostate, prevent the obstruction of urine flow by blood clots

expected: link pink drainage w/ few clots

what is cushing triad, and what are the respirations

bradycardia, HTN, and SLOW IRREGULAR RESP, (Cheyenne-strokes)

patient educatino for EEG

hold meds: depressants, stimulants, antiseizure meds

avoid caffeine 8 hours prior

have pt wash hair before prod,

when someone has a thyroidectomy, what are the susceptible too

low PTH levels because the blood supply to parathyroid gets damage leading to hypoCa and hyperP

diabetic foot care

check for cuts, blisters swelling and sores to prevent infection

AVOID SOAKING FEET, wash feet in lukewarm water and dry thoroughly → avoid to prevent maceration and skin breakdown

apply lotion after washing feet, avoid between toes though

dont walk barefoot

avoid tight stockings, could impair circulation

trim nails across to avoid ingrown toenails

avoid heating pads or water bottles to avoid burns

alert HCP if foot injury

what causes of metabolic acidosis

• Renal disease -> accumulation of acids the kidney normally excretes

• DKA

• Loss of bicarb

• Diarrhea (bicarb loss)

• shock, like septic, lactic acid build up

what causes metabolic alkalosis

NG suction ((less acid)

vomit (less acid)

diuretics (excess bicarb resorption)

too much of bicarb

what to be careful of when doing fecal impaction

pt has a hx of dysrhythmias, it can exacerbate CV problems

what is obstructive sleep apnea and what causes it

a sleep disorder characterized by recurrent episodes of upper airway obstruction, leading to periods of brief apnea. Muscles in the pharynx and oral cavity relax during sleep and cause airway narrowing; chest and abd movements involved with respiration continue despite narrowing,leading to snoring. the obstructed airway causes pt to become hypoxic and wake up.

RF included: menopause (something dec in muscle tone)

BMI > 30 and neck circumference > 16in

deviated nasal septum

alch, smoke, >65 and HF

what are the 5 P’s of houlry rounding, like what should you assess

pain, potty, possessions, positioning, personals needs

for a peg tube, how do you assess gastric residual volume

ph testing, less than 5 indicates gastric placement

air into tube is not accurate

additional note: for peg tube feedings, minimize the risk of aspiration by re-instilling aspirated stomach contents before adm the feeding

how do you catch a pt when they call

minimizie injury by extending one leg and sliding the pt down that leg to the floor

what do gait belts do

provide sturdy grip to guide pt, NEVER SHOULD BE USED TO LIFT OR hold a pt up

what are indications of needing blood transufsion

trauma, chronic anemia, tx-induced anemia, GI bleed

if stool is black, dont need transufsion, it is a slow bleed

why should you avoid canned food

it can contain high Na which can contribute to HTN

what is included in a diabetic diet

carb intake with foods that will not spike blood sugar levels

diet teaching should focus on balancing carbs with protein and healthy fats while being aware of the portion size

pressure injury risk factors

impaired sensory perception - also think of like neuropathy for diabetes pt

impaired mobility and inactivity

friction and shear

presence of moisture

impaired nutrition - counts for stage 5 kidney disease, these pt need reduced protein when you want it

definition of standard precatuion

measure implemented to prevent infection tranmission that are appropriate for ALL pt regardless of infection status.

• so like right PPE for pt with meningitis is already standard

• do not need to put gloves on for diaphoresis

ekg finding for hypoK

ST depression, prominent U wave, peaked p wave

slightly prolonged PR interval

ekg finding for hyperK

widened QRS

ST depression

TALL PEAK T WAVE

flat P wave, prolonged PR interval

when should sputum be collected

in the morning so they can cough up secretions accumulated throughout the night

mouth should be rinsed with water before collection

doff order

gloves, goggles, gown then mask

in a negative pressure room (airborne) where should the nurse take off PPE

anteroom, this is where the PPE is removed

what diff kind of PPE do you put on for trach suctioning

put on eye protection, remember

potential of spraying or splashing of bodily fluids such as suctioning pt, wound care, childbirth should wear a face mask

proper sleep hygiene

if unable to sleep for 30 mins in bed, GET OUT OF BED AND ENGAGE IN A RELAXING ACTIVITY

maintain consistent sleep sched

avoid daytime napping

exercise right before bed can INTERFERE with sleep

alch should be avoided, same with large meals

RF for falls

impaired mobility: muscle weakness, paralysis (stroke) or musculoskeletal conditions (arthritis)

impaired balance: neuro (parkinsons), hemodynamic (orthostatic hypo), meds (benzo, opioid)

impaired mental status: confusion, disorientation, altered judgement (impulsivity)

impaired sensory perception: VISUAL

impaired bladder or bowel function: incontinence, urgency, freq

environmental hazards: tripping, poorly lit room, improper use of assistive devices

chronic conditions: illness, dementia, diabetes, PAIN

infiltration

when IV becomes dislodged from or peforates the vein, allowing IV solution to leak into surroiudning tissue

s/s: localized pain, coolness, redness, swelling, IV pump occlusion, fluid leakage and causing MOIST dressing

phlebiits

inflammation of vein caused by irritation

• s/s: pain, redness/coolness BUT NOT FLUID leakage

never adjust O2 without speaking with PCP

never adjust O2 without speaking with PCP

info for NRB

how it works:

• open during expiration to vent CO2 out, closes during inspiration to prevent rebreathing expired room air

never want the bag to be fully deflate, partially inflate at all times is what you want

should be no gaps, not no 2 finger fit

set rate should be 10-15:, if not sufficient risk of suffocation

how to prevent CAUTI

perform perineal care twice per shift with soap and water minimizes bacterial contamination

hang collection bag below level of bladder

prevent kinks, bends and dependent loops

avoid any hot pad on direct skin

avoid any hot pad on direct skin

fire response interventions in order

RACE

Rescue clients

Activate alarm system

confine fire by closing doors

extinguish fire

what causes resp acidosis

slow breathing, obstructed airway, hypovent

the slow breathing creates retention of CO2

what causes resp alkalosis

breathing too fast, hypervent, tachypnea

anxiety, panic attack

what causes metabolic acidosis

excess bicarb or ACID PROD

severe diarrhea → bicarb loss

DKA (ketone acid buildup)

shock, sepsis → lactic acid buildup

renal failure

what causes metabolic alkalosis

excess bicarb, OR acid loss

suctioning or vomit (loss of gastric acid)

diuretics (excess bicarb reabsorption)