DO NOT delegate what you can EAT!
E – evaluate
A – assess
T – teach
addisons= down, down down up down
cushings= up up up down up
addisons= hyponatremia, hypotension, decreased blood vol, hyperkalemia, hypoglycemia
cushings= hypernatremia, hypertension, incrased blood vol, hypokalemia, hyperglycemia
No Pee, no K (do not give potassium without adequate urine output)
EleVate Veins; dAngle Arteries for better perfusion
A= appearance (color all pink, pink and blue, blue [pale])
P= pulse (>100, < 100, absent)
G= grimace (cough, grimace, no response)
A= activity (flexed, flaccid, limp)
R= respirations (strong cry, weak cry, absent)
TRANSMISSION-BASED PRECAUTIONS:
AIRBORNE
My – Measles
Chicken – Chicken Pox/Varicella
Hez – Herpez Zoster/Shingles
TB
or remember…
MTV=Airborne
Measles
TB
Varicella-Chicken Pox/Herpes Zoster-Shingles
Private Room – negative pressure with 6-12 air exchanges/hr
Mask, N95 for TB
DROPLET
think of SPIDERMAN!
S – sepsis
S – scarlet fever
S – streptococcal pharyngitis
P – parvovirus B19
P – pneumonia
P – pertussis
I – influenza
D – diptheria (pharyngeal)
E – epiglottitis
R – rubella
M – mumps
M – meningitis
M – mycoplasma or meningeal pneumonia
An – Adenovirus
Private Room or cohort
Mask
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CONTACT PRECAUTION
MRS.WEE
M – multidrug resistant organism
R – respiratory infection
S – skin infections *
W – wound infxn
E – enteric infxn – clostridium difficile
E – eye infxn – conjunctivitis
SKIN INFECTIONS
VCHIPS
V – varicella zoster
C – cutaneous diphtheria
H – herpez simplex
I – impetigo
P – pediculosis
S – scabies
- Air/Pulmonary Embolism (S&S: chest pain, difficulty breathing, tachycardia, pale/cyanotic,
sense of impending doom) –> turn pt to left side and lower the head of the bed. - Woman in Labor w/ Un-reassuring FHR (late decels, decreased variability, fetal
bradycardia, etc) –> turn on left side (and give O2, stop Pitocin, increase IV fluids) - Tube Feeding w/ Decreased LOC –> position pt on right side (promotes emptying of the
stomach) with the HOB elevated (to prevent aspiration) - During Epidural Puncture –> side-lying
- After Lumbar Puncture (and also oil-based Myelogram)–> pt lies in flat supine (to prevent
headache and leaking of CSF) - Pt w/ Heat Stroke –> lie flat w/ legs elevated
- During Continuous Bladder Irrigation (CBI) –> catheter is taped to thigh so leg should be
kept straight. No other positioning restrictions. - After Myringotomy –> position on side of affected ear after surgery (allows drainage of
secretions) - After Cataract Surgery –> pt will sleep on unaffected side with a night shield for 1-4
weeks. - After Thyroidectomy –> low or semi-Fowler’s, support head, neck and shoulders.
- Infant w/ Spina Bifida –> position prone (on abdomen) so that sac does not rupture
- Buck’s Traction (skin traction) –> elevate foot of bed for counter-traction
- After Total Hip Replacement –> don’t sleep on operated side, don’t flex hip more than 45-
60 degrees, don’t elevate HOB more than 45 degrees. Maintain hip abduction by separating
thighs with pillows. - Prolapsed Cord –> knee-chest position or Trendelenburg
2 - Infant w/ Cleft Lip –> position on back or in infant seat to prevent trauma to suture line.
While feeding, hold in upright position. - To Prevent Dumping Syndrome (post-operative ulcer/stomach surgeries) –> eat in
reclining position, lie down after meals for 20-30 minutes (also restrict fluids during meals, low
CHO and fiber diet, small frequent meals) - Above Knee Amputation –> elevate for first 24 hours on pillow, position prone daily to
provide for hip extension. - Below Knee Amputation –> foot of bed elevated for first 24 hours, position prone daily to
provide for hip extension. - Detached Retina –> area of detachment should be in the dependent position
- Administration of Enema –> position pt in left side-lying (Sim’s) with knee flexed
- After Supratentorial Surgery (incision behind hairline) –> elevate HOB 30-45 degrees
- After Infratentorial Surgery (incision at nape of neck)–> position pt flat and lateral on
either side. - During Internal Radiation –> on bedrest while implant in place
- Autonomic Dysreflexia/Hyperreflexia (S&S: pounding headache, profuse sweating, nasal
congestion, goose flesh, bradycardia, hypertension) –> place client in sitting position (elevate
HOB) first before any other implementation. - Shock –> bedrest with extremities elevated 20 degrees, knees straight, head slightly
elevated (modified Trendelenburg) - Head Injury –> elevate HOB 30 degrees to decrease intracranial pressure
- Peritoneal Dialysis when Outflow is Inadequate –> turn pt from side to side BEFORE
checking for kinks in tubing (according to Kaplan) - Lumbar puncture => AFTER the procedure, the client should be placed in the supine
position for 4 to 12 hrs as prescribed. (Saunders 3rd ed p. 229)
Demorol for pancreatitis, NOT morphine sulfate
Myasthenia Gravis: worsens with exercise and improves with rest.
Myasthenia Crisis: a positive reaction to Tensilon–will improve symptoms
Cholinergic Crisis: caused by excessive medication-stop med-giving Tensilon will make it worse
Head injury medication: Mannitol (osmotic diuretic)-crystallizes at room temp so ALWAYS use
filter needle
Prior to a liver biospy its important to be aware of the lab result for prothrombin time
From the a** (diarrhea)= metabolic acidosis
From the mouth (vomitus)=metabolic alkalosis
Myxedema/hypothyroidism: slowed physical and mental function, sensitivity to cold, dry skin
and hair
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Graves’ disease/hyperthyroidism: accelerated physical and mental function; sensitivity to
heat, fine/soft hair
Thyroid storm: increased temp, pulse and HTN
Post-thyroidectomy: semi-Fowler’s, prevent ncek flexion/hyperextension, trach at bedside
Hypo-parathyroid: CATS – convulsions, arrhythmias, tetany, spasms, stridor (decreased
calcium), high Ca, low phosphorus diet
Hyper-parathyroid: fatigue, muscle weakness, renal calculi, back and joint pain (increased
calcium), low Ca, high phosphorus diet
Hypovolemia – incrased temp, rapid/weak pulse, increase respiration, hypotension, anxiety,
urine specific gravity >1.030
Hypervolemia – bounding pulse, SOB, dyspnea, rares/crackles, peripheral edema, HTN, urine
specific gravity <1.010; Semi-Fowler’s
Diabetes Insipidus (decreased ADH): excessive urine output and thirst, dehydration,
weakness, administer Pitressin
SIADH (increased ADH): change in LOC, decreased deep tendon reflexes, tachycardia, n/v/a,
HA; administer Declomycin, diuretics
Hypokalemia: muscle ewakness, dysrhythmias, increase K (raisins, bananas, apricots, oranges,
beans, potatoes, carrots, celery)
Hyperkalemia: MURDER – muscle weakness, urine (oliguria/anuria), respiratory depression,
decreased cardiac contractility, ECG changes, reflexes
Hyponatremia: nausea, muscle cramps, increased ICP, muscular twitching, convulsion; osmotic
diuretics, fluids
Hypernatremia: increased temp, weakness, disorientation/delusions, hypotension, tachycardia;
hypotonic solution
Hypocalcemia: CATS – convulsions, arrhythmias, tetany, spasms and stridor
Hypercalcemia: muscle weakness, lack of coordination, abdominal pain, confusion, absent
tendon reflexes, sedative effect on CNS
HypoMg: tremors, tetany, seizures, dyrshythmias, depression, confusion, dysphagia; dig toxicity
HyperMg: depresses the CNS, hypotension, facial flushing, muscle ewakness, absent deep
tendon reflexes, shallow respirations, emergency
Addison’s: hypoNa, hyperK, hypoglycemia, dark pigmentation, decreased resistance to stress,
fractures, alopecia, weight loss, GI distress
Cushings: hyperNa, hypoK, hyperglycemia, prone to infection, muscle wasting, weakness,
edema, HTN, hirsutism, moonface/buffalo hump
Addisonian crisis: n/v, confusion, abdominal pain, extreme weakness, hypoglycemia,
dehydration, decreased BP
Pheochromocytoma: hypersecretion of epi/norepi, persistent HTN, increased HR,
hyperglycemia, diaphoresis, tremor, pounding HA; avoid stress, frequent bating and rest breaks,
avoid cold and stimulating foods, surgery to remove tumor
- Neuroleptic malignant syndrome (NMS):
-NMS is like S&M;
-you get hot (hyperpyrexia)
-stiff (increased muscle tone)
-sweaty (diaphoresis)
-BP, pulse, and respirations go up &
-you start to drool
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