NCLEXMedSurg Master Study Guide

NCLEX/MedSurg Master Study Guide

Nursing Process:

A - assessment D - diagnosis O - outcome planning (specific, measurable, timely) Ex. The patient will walk 300 ft in the hallway by the end of the shift (3pm) P - planning Planning is done WITH patient, not FOR them. Let them assist in making goals that they see as doable I - intervention E - evaluation Reflecting on whether the goal was met/ what could be changed to help the pt. Reach it  not evaluating **ourselves** we are evaluating whether or not the goal was MET

Nursing Virtues:

Beneficence - “do good” Non maleficence - “do no harm” Veracity - telling the truth, never lying or trying to deceive a patient If you make a med error, if a patient asks you about their disease Fidelity - keeping your promises Autonomy - pt. Is allowed (and supported) to make their own decisions Choosing treatment plans, right to advance directives, DNR orders, etc.Justice - providing fair care to all Providing equal care to patients no matter what (age, sex, race, LGBT, religion, disease) Confidentiality - keeping things between you and the patient If a patient tells you something, it should remain between the two of you The ONLY times you can break confidentiality are when the patient’s safety is involved (ex. Pt. is going to commit suicide, mandatory reporting of elder abuse, etc) Privacy - pt. Is entitled to their own personal privacy Closing the door /curtain when they are physically exposed/leaving the room if the patient is on the toilet

Normal Lab Values:

Digoxin 0.5-2, anything above 2 will give nausea, vomiting, diarrhea, and VISUAL disturbances (yellow halo around anything they are looking at) If the patient is hypokalemic (low potassium), makes it easier for them to go into Dig.toxicity Hold digoxin if their heart rate is below 60 bpm Lithium - 0.5-1.5, hold for anything higher! Tremors, confusion, seizures etc.Typically used for bipolar disorder Never double up 22 on lithium doses if you miss one -- safety!Lithium messes with their sodium! They need to stay stable with their sodium intake and consult their doctor before vigorous work outs / saunas / etc. because sweat can cause them to lose too much sodium. When they lose sodium, it makes it easier for lithium toxicity to occur Phenytoin/Dilantin 10-20 Used most often for seizure disorders Blood levels have to monitored over time to adjust dosage -- pt. Gets frequent lab draws Phenytoin reaction can cause anemia - dyspnea, fatigue, paleness, rashes, swelling and bleeding of the gums.

BUN: 10-20, indicative of kidney function, monitor for nephrotoxic drugs

Creatinine: 0.6-1.3, indicative of kidney function, monitor for nephrotoxic drugs

NCLEX MEDSURG MASTER STUDY GUIDE

INR (Warfarin) normal 1-2, on warfarin want it to be 2-3 to prevent clots PT (Warfarin) normal 11-13 seconds,want it to be 1.5-2x longer than that aPTT (Heparin) (remember 2 T’s in H) normal 30-45 seconds, want it to be 1.5-2.5x longer than that. <45sec =clots!Hgb 12-18% HCt female: 37-47%, male: 42-52% In pregnancy, H&H can **appear** lower because the woman’s plasma volume is expanding -- does not mean they are necessarily bleeding if H&H dips a little bit CVP (central venous pressure, in the heart) 2-6, low CVP is dehydration, high CVP is fluid overload High CVP = rales in lungs, JVD, dyspnea, tachycardia Low CVP = shock, signs of dehydration Platelets 150,000-400,000, below 150 we are worried about bleeding - bleeding precautions!ANC (Absolute neutrophil count) - ~2200-7000

Minimum urine in an hour: 30ml/hr

GFR (glomerular filtration rate): should be above 60 with healthy kidneys

WBC’s: 4,000-11,000

Sodium: 135-145 - low/high sodium causes neuro problems = confusion, altered LOC, coma

ALL things potassium:

Potassium: 3.5-5 -- altered potassium = HEART Dysrhythmias, mainly V-tach

Foods with a lot of potassium: bananas, sweet potatoes

We NEVER give potassium via IV push, it can kill the person!!K+ always given on IV pump, needs to be SLOW over 2-4 HOURS so that we don’t change their K+ too quickly; never more than 10 mEq/hr If patient has hyperkalemia - Give IV insulin and then immediately give IV dextrose - forces potassium back into cells so it is not floating around in the blood causing problems Hyperkalemia: HIGH potassium = peaked T waves, wide QRS, wide PR (everything is UP) Hypokalemia: LOW potassium = U wave at the end, depressed “low waves”, muscle cramps = especially CALF -- if pt has low potassium they can go into torsades = BAD  Also tell patient to avoid “salt substitutes” in their diet because those oftentimes contain potassium in them instead

Calcium:

normal 8.6-10.2 Low calcium = crazy muscles!Laryngospasms*** priority because this is your throat! Airway compromise!Positive chvostek / trousseau’s sign Seizures Muscle tightness and cramping Hyperactive bowel sounds, diarrhea When to worry about low calcium?? After a thyroidectomy!! The parathyroid glands (which break down bone and put calcium into the blood) are on the thyroid….. So sometimes during surgery the parathyroid glands can be removed with the thyroid!! This will cause low low calcium = look for the low calcium signs when they get back from thyroid surgery!

High calcium = acts as a sedative Low grade deep tendon reflexes Hypoactive bowel sounds Respiratory depression Drug Antidotes Warfarin -Vitamin K (also found in leafy green vegetables) Heparin - Protamine sulfate Tylenol - N-Acetylcystine (Mucomyst) 17 doses and a loading dose Digoxin - Digibind Iron - Desferoxamine, binds to iron in the blood and excretes it so you don’t go into metabolic acidosis Cholinergic drugs - atropine Opioids - naloxone (Narcan) -- can be given nasal spray / IV/ IO Drugs & Drug Tips Buccal medications - go onto the mucosa of the cheek You don’t want them to swallow it or take it out - leave the medication on the cheek until it dissolves completely May tingle or burn a little bit - this is normal Extended release capsules - ex. Toprol XL, aspirin- ER.Cannot chew, break, split the capsule etc.If person cannot swallow, need to call MD to change the order. Do NOT alter the extended release medication because it will alter absorption Salmeterol inhaler = maintenance inhaler!Use everyday regardless of whether you feel symptomatic Not used in emergencies, sudden asthma exacerbation -- always reach for albuterol “Statin” meds - ex. Atorvastatin, Simvastatin. used to lower cholesterol and triglycerides We want to lower the LDL cholesterol Statin’s lower cholesterol by acting on the liver = potential for liver damage!If they have elevated AST, ALT but lowered trigs/cholesterol = think statins Steroids - ex. Prednisone. NEVER stop steroids suddenly! Patient needs to taper off their steroids slowly so there are no complications

Long-term steroid use has a lot of side effects:

Weight gain - Moon face, cushy neck Hirsutism - abnormal hair growth Increased acne Delayed wound healing, increased risk of infection GI ulcers High blood pressure, high blood sugar Spironolactone - potassium SPARING diuretic, monitor their K+ VERY closely -could get high We do NOT want them to increase intake of potassium Do not give replacement Meq’s of potassium with spirinolactone! Ex. If they are ordered for spirinolactone and 40meq’s of potassium = CALL MD, question order They also shouldn’t use “salt substitutes” because they contain potassium too

Tetracycline/ Doxycycline Antibiotics:

Always take on empty stomach for best absorption CANNOT take when pregnant Photosensitivity - make sure you wear sunscreen outside Drink plenty of fluids throughout the day

Can interfere with your birth control! Use multiple methods of birth control WAIT 2 hours before taking anything with iron or calcium Give IRON with ORANGE JUICE Iron is well absorbed with vitamin C Do NOT give Iron with any calcium products (milk, dairy, antacids, etc.) because it reduces absorption MAOI’s: you cannot have a diet high in TYRAMINE because it will cause blood pressure to skyrocket = hypertensive crisis What kinds of foods are high in tyramine? Avocados, beer, blue cheese, meats like salami, bologna, processed foods etc. teas cokes and coffees too (caffeine) ALSO - no over the counter cold medications with MAOI’s Drugs - “Going to PANAMA” - Parnate, Nardil, Marplan

Warfarin/Coumadin: if on warfarin, INR should be between 2-3 to be therapeutic

Patient has to have blood levels checked frequently Intake of vitamin K needs to be consistent, do NOT increase/decrease leafy green veggies NEVER change the dosage of warfarin on your own or double up on doses Bleeding precautions ONLY electric razors - can bleed profusely if using regular razor Soft toothbrush bristles Limit unnecessary needle sticks, blood draws, tubes/drains No aspirin, No NSAIDs - increases risk of bleed Treat constipation early -- give stool softeners to prevent straining because they can cause a bleed if they push too hard and stool is hard

Inhaled Corticosteroids:

Risk of thrush (fungal infection) in the mouth Make sure you rinse your mouth out and brush teeth after using inhaler Always give the bronchodilator first (albuterol) to open the airway, then the steroid! We want it to get down into the lungs Inhaling corticosteroids - it is NORMAL for pt. To feel nervous, have heart racing feeling, tachycardia -- does not mean something is wrong Propofol - used for sedation; CANNOT be given by general floor nurses! Immediately question it if the doctor asks you to give propofol on a general floor Disulfiram - for getting off alcohol Cannot use ANY product with alcohol in it - even cooked foods/ mouthwashes If you stop the med, wait at least two weeks before having any alcohol products Avoid chocolate and caffeine too Still need to attend therapy sessions! This is not a cure for alcoholism Donepezil - for confusion Notify MD if they are throwing up coffee ground vomit = bleeding!Alendronate - take on empty stomach but with FULL glass of water to get it to go down and sit up for at least 30 minutes after taking it Used for osteoporosis, it’s a bisphosphonate IV calcium - give VERY slowly, can cause cardiac arrest!Never give more than 1-2ml/min MMR vaccine - given SUBQ, not IM MMR not given if allergic to egg or gelatin because MMR is cultured in egg Epoetin - stimulates bone marrow to make more red blood cells!Reduces the chance that the patient will need a blood transfusion