Scope of Practice - determined by a state's Nurse Practice Act

Standards of Practice - established by the nursing profession, i.e., the American

Nurses
Association
Standard of Care - institutional policy and procedure documents
SBAR technique - provides a standardized framework for communication between mem
bers of the health care team
S = situation (a concise statement of the problem)
B = background (pertinent and brief information related to the situation)
A = assessment (analysis and considerations of options - what you found/think)
R = recommendation (action requested/recommended - what you want)
2. "I PASS the BATON" - used to improve "handoffs" and transitions in health car
e, with opportunities to ask questions, clarify, and confirm
I = introduction (introduce yourself and your role/job)
P = patient (name, identifiers, age, gender, location)
A = assessment (presenting chief complaint, vital signs and symptoms and diagnos
is)
S = situation (current status/circumstances, including code status, recent chang
es, response to treatment)
S = safety concerns (critical lab values/reports, socio-economic factors, allerg
ies, alerts such as falls, isolation,
B = background (co-morbidities, previous episodes, current medications, family h
istory)
A = actions (what actions were taken or are required and provide brief rationale
)
T = timing (level of urgency and explicit timing, prioritization of actions)
O = ownership (who is responsible - nurse/doctor/team and patient/family respons
ibilities)
N = next (what will happen next? anticipated change? what is the PLAN? What is t
he contingency plan?)
CUS - a process used to more effectively advocate for clients when there is a co
ncern
C = concern ("I am concerned...")
U = uncomfortable ("I am uncomfortable...")
S = safety ("this is unsafe...")
Five Rights of Delegation
Right Task
Right Circumstances
Right Person
Right Direction/Communication
Right Supervision/Evaluation
The 4 C's of Communication
1. Clear - Does the team member understand what I am saying?
2. Concise - Have I confused the direction by giving too much unnecessary inform
ation?
3. Correct - Is the direction given according to policy, procedures, job descrip
tion, and the law?
4. Complete - Does the delegatee have all the information necessary to complete
the task?
Remember the steps in the Nursing Process - A Delicious PIE
A= Assessment
D= Diagnosis
P= Planning
I= Implementation

E= Evaluation
Documentation has six key components (CO-ACTS)
C onfidential
O rganized (chronologically)
A ccurate
C omplete
T imely
S ubjective and objective data
REMEMBER IT!
A former client sues a nurse for negligence. The client must prove that the nurs
e not only committed a breach of duty but that this breach of duty was the proxi
mate cause of any damages incurred by the client.
If there is a fire, remember R-A-C-E:
R=Rescue or remove clients
A=Activate fire alarm system
C=Contain fire by closing windows and doors
E=Extinguish flames (with fire extinguishers)
Fall & injury prevention
1. Assesses client for risk factors
Use the mnemonic FRAIL MOM & DAD for assessing the geriatric client in the prima
ry care setting:
Falls
Relative or caregiver strain
Activities of daily living
Incontinence
Living situation
Memory Impairment
Oculo-otic impairment (visual and auditory problems)
Malnutrition
Drugs
Advance directives
Depression
Test-taking Tips: Remember that safety always takes priority when it is an option
and the question is about the priority.
calculate due date: Naegele's Rule (when first day of last normal period = N, th
en due date is N plus 7 days,
minus 3 months, plus 1 year)
The delivery process is described in these terms:
Fetal Station: the relationship between the presenting part of the baby with the
mother's pelvis
Fetal Lie: the relationship between the head to tailbone axis for both the fetus
and the mother
Fetal Attitude: the relationship of the fetal body parts to one another
Fetal Presentation: portion of the fetus that enters the pelvic inlet first (ceph
alic, breech, shoulder)
Maternal Postpartum Assessment: BUBBLE-HE
B:
U:
B:
B:
L:
E:

Breasts
Uterine fundus
Bladder function
Bowel function
Lochia
Episiotomy (Perineum)

H: Homan's sign (legs)

E: Emotions
Postpartum assessments that would require notifying the health care provider:
Maternal
Temperature greater than 100.4 F (38 C)
Increased lochia, clots or foul odor
Perineal pain or swelling
Calf tenderness
Appetite loss
Sleep disturbances
Continued mood swings or depression
Elimination problems (burning, frequency or urgency of urination, or persiste
nt constipation)
Newborn
Temperature greater than 100.4 F (38 C)
Poor feeding effort
Vomiting or diarrhea
Inconsolable crying
Inability to arouse; exceedingly sleepy
Yellowing of the skin
No wet diaper in eight hours
Postpartum assessment: BUBBLE
B=Breasts
U=Uterus
B=Bowels
B=Bladder
L=Lochia
E=Episiotomy/C-section incision
E---can also stand for maternal emotions about the
outcomes of the birth and the new baby
Erikson's Eight Stages of Psychosocial Development
Name of Stage
Age*
Major Characteristic(s)
Trust vs. Mistrust
Birth to 18 months
The development of trust is based on the dependability and quality of the child'
s caregivers, i.e., feeding
Autonomy vs. Shame and Doubt
Toddlers
(18mts to 3 years-old)
Children develop a greater sense of personal control, i.e., toilet training
Initiative vs. Guilt
Preschool
(3 to 5 years-old)
Children begin to assert their power and control over the world through directly
play and other social interaction, i.e., independence
Industry vs. Inferiority
School age
(6 to 11 years-old)
Through social interactions, children begin to develop a sense of pride in the a
ccomplishments
Identity vs. Role Confusion
Adolescence

(12 to 18 years-old)
Exploring independence and developing a sense of self
Intimacy vs. Isolation
Early adulthood
(18 to 40 years-old)
Exploring personal relationships is important, especially love relationships
Generativity vs. Stagnation
Adulthood
(40 to 64 years-old)
Building careers and family
Integrity vs. Despair
Older adult
(65 years to death)
Focused on reflecting back on life
Can prevent or minimize illness and disability REMEMBER IT
Primary - Prevent
Secondary - Screen
Tertiary - Treat
CN I: Olfactory
Recall Tip: Odor = one (nose)
Identify smells
Inability to identify arom
CN II: Optic
Visual acuity and full visual fields
Fundoscopic exam reveals no pathology
Inability to identify full visual fields
Total or partial blindness in one or both eyes
CN III: Oculomotor
Follows up to six cardinal positions of gaze
Pupils are unremarkable
Exhibits no nystagmus and no ptosis
One or both eyes will deviate from normal position
CN IV: Trochlear
Same as CN III: Oculomotor
Same as CN III: Oculomotor
CN V:Trigeminal
Clenches teeth with firm bilateral pressure
No lateral jaw deviation with mouth open
Differentiates sharp and dull sensations on face
Corneal reflex: blinks when cotton is touched to each cornea
Absent or one-sided blinking of eyelids
CN VI: Abducens
Same as CN III: Oculomotor
Same as CN III: Oculomotor
CN VII: Facial
Facial symmetry with and without smile
Can raise eyebrows symmetrically and grimace
Can shut eyes tightly
Can identify sweet, sour, salt or bitter on the anterior tongue
Irregular and unequal facial movements
Inability to taste or to identify salt, sweet, sour, or bitter substances on the
anterior two-thirds of tongue
Inability to smile symmetrically
CN VIII: Auditory (Acoustic)

Recall Tip: Ear = eighth

Can hear a whisper at 1 to 2 feet
Can hear a watch tick at 1 to 2 feet
Does not lateralize the Weber test
Can hear air conduction better than bone conduction in the Rinne test
Inability to hear spoken word
CN IX: Glossopharyngeal
Swallows and speaks without hoarseness
Palate and uvula rise symmetrically when client states: "ah"
Bilateral gag reflex
Can identify taste on the posterior tongue
Unequal or absent rise of uvula and soft palate as client states: "ah"
Absent gag reflex
Inability to taste or identify taste on the posterior tongue
CN X: Vagus
same as CN IX: Glossopharyngeal
same as CN IX: Glossopharyngeal
CN XI: Spinal Accessory
Resists head turning
Can shrug against resistance
Weak or absent should and neck movement
CN XII: Hypoglossal
Can stick tongue out and move it from side to side
Can push tongue against resistance
REMEMBER IT
There are a lot of mnemonics to remember the names of the 12 cranial nerves; her
e's one of the "cleaner" versions:
On Old Olympus Towering Tops A Fin And German Viewed Some Hops
Here's a version to help remember which of the cranial nerves carry sensory, mot
or, or both types of impulses (S=sensory, M=motor, B=both): Some Say Marry Money
But My Brother Says Big Business Makes Money
assist in discussions of future plans as appropriate
REMEMBER IT
Tasks of mourning (common to the models of grief): R E A L
Real - accept that the loss is real
Experience the emotions associated with the loss
Adjust or re-adjust to life and activities
Let go and move on with one's own life
Stress response involves both localized and general adaptation
REMEMBER IT
PANIC episode:
Palpitations
Abdominal distress
Nausea
Increased perspiration
Chest pain, chills, choking
Warning Signs of Suicidal Thoughts or Plans
Previous suicide attempt
Threatening to commit suicide
Giving away prized possessions
Collecting and discussing information on suicide methods

Expressing hopelessness, helplessness, and anger at self or world

Death or depression in talk, writing, or artwork
Client states or suggests s/he would not be missed
Client expresses no hope for the future
Self-mutilation
Recent loss of friend or family member through natural death, accident or su
icide; other major loss such as job or divorce
Acute personality changes such as unusual withdrawal or aggressiveness, mood
iness, or taking risks
Sudden change in academic performance, truancy, or running away
Physical symptoms such as insomnia or excessive sleeping, headaches, stomach
aches
Use or increased use of potentially addictive substances
Low self esteem; feeling worthless, ashamed, guilty, self-hating
Putting affairs in order, tying up loose ends, changing a will
Communication with individuals with aphasia or dementia is enhanced if you remem
ber the K.I.S.S. technique:
Keep It Short and Simple!
The only FDA-approved type of medications used to treat this disorder are SSRIs.
Post-traumatic stress disorder (PTSD)
Electroconvulsive therapy (ECT) is used to treat a severe form of this disorder.
Depressive disorder
Russells sign is observed with this disorder.
Bulimia nervosa
A person with this disorder may experience drastic changes in mood accompanied b
y extreme changes in energy, activity, sleep and behavior.
Bipolar disorder
A drug holidays are sometimes used in the management of this disorder.
Attention deficit hyperactivity disorder (ADHD)
A person with this disorder recognizes their behavior is excessive and unreasona
ble but cannot stop the behavior.
Obsessive-compulsive disorder
A person with this disorder experiences hallucinations and delusional thoughts.
Schizophrenia
Malabsorption syndrome and Wernicke-Korsakoff syndrome are associated with this
disorder.
(Chronic) Alcoholism
This disorder includes Alzheimers disease, traumatic brain injury, and Huntingtons
disease.
Neurocognitive disorders
The child with this disorder has difficulties with social interaction and verbal
and nonverbal communication and also exhibits repetitive behaviors.
Autism spectrum disorder (ASD)
water soluble : vitamin C and B-complex vitamins (thiamin, riboflavin, niacin, p
antothenic acid, biotin, B6, folate, B12)
cannot be stored in body daily intake required

 excess is eliminated daily

little risk of toxicity
ii. fat soluble : A, D, E, K
stored in body (primarily in liver and adipose tissues)
absorbed by the body from the intestinal tract
risk of toxicity
Major electrolytes
a. anions
i. chloride
most abundant anion in extracellular fluid
helps balance sodium
normal lab value for serum chloride is 95-105 mEq/L
ii. bicarbonate
part of bicarbonate buffer system
limits the drop in pH by combining with an acid to form carbonic acid and a salt
important in acid-base analyses (arterial blood gases [ABG])
normal arterial bicarbonate 22-26 mEq/L, normal venous bicarbonate 24-30 mEq/L
iii. phosphate
participates in cellular energy metabolism
combines with calcium in bone
assists in structure of genetic material
balanced by parathyroid gland, along with calcium
normal serum phosphate level 2.8-4.5 mg/dL
b. cations
i. sodium
most abundant cation in extracellular fluid
regulates cell size via osmosis
needed to maintain water balance, transmit nerve impulses, and contract muscles;
used to control blood pressure and blood volume regulates acid-base balance by ex
changing hydrogen ions for sodium ions in kidney
sodium is regulated by salt intake, aldosterone, and urinary output
normal lab value for serum sodium is 135-145 mEq/L
large changes may occur with minimal clinical findings
low levels of 125 mEq/L or less result in mental confusion, hostility, hallucina
tions
excess levels may result in hypertension or generalized edema, called anasarca
ii. potassium
most abundant cation of intracellular fluid
potassium pump draws potassium into cell
essential for polarization and repolarization of nerve and muscle fibers
regulates neuromuscular excitability and muscle contraction
regulated by kidneys
normal lab value for serum potassium is 3.5-5 mEq/L
small changes may result in significant clinical findings
high and/or low findings may result in a fast or slow heart rhythm and muscle fu
nction with results of
cramping in abdomen or legs
iii. calcium
needed for cardiac contraction, healthy bones and teeth, functioning of nerves a
nd muscles, clotting of blood
vitamin D is needed for calcium absorption
normal values - total calcium 8.5-10.5 mg/dL
hypercalcemia
causes:
hyperparathyroidism,
metastasis of cancer,

Pagets disease of bone,

prolonged immobilization
findings:
weakness,
paralysis,
decreased deep tendon reflexes
hypocalcemia
causes:
rickets,
vitamin D deficiency,
renal failure,
pancreatitis,
chelation therapy,
hypoparathyroidism
findings:
muscle tingling,
twitching,
tetany iv. magnesium
about half of total body magnesium is found in bone
needed for more than 300 biochemical reactions - involved in normal muscle and n
erve function, heart rhythm, immune system, blood sugar regulation, blood pressu
re, energy metabolism, protein synthesis, and bone strength
normal values - 1.5-2.5 mEq/L
hypermagnesemia
causes:
chronic renal disease,
overuse of magnesium-containing antacids as Maalox and Mylanta,
Addisons disease,
uncontrolled diabetes mellitus
findings:
lethargy,
nausea,
vomiting,
slurred speech,
muscle weakness,
paralysis, d
ecreased deep tendon eflexes,
slowing of cardiac conduction
hypomagnesemia
causes:
malnutrition,
toxemia in pregnancy,
malabsorption,
alcoholism,
diabetic acidosis
findings:
mood irritability,
cardiac irritability,
muscle tingling,
twitching,
tetany,
delirium,
convulsions
Types of Vegetarian Diets
Vegan: refrains from eating animal products
Lacto-ovo vegetarian: consumes eggs and dairy products but excludes meat, poultr

y, seafood
Lacto-vegetarian: consumes dairy products, but excludes eggs, meat, poultry, sea
food
Remember the reversible causes of urinary incontinence using the mnemonic D.R.I.
P.
Delirium
Restricted mobility (or Retention [urinary])
Infection (or Inflammation or Impaction [fecal])
Pharmaceuticals (or Polyuric states)
Pain Management ABCs
A- Assess the client by asking about the pain
B- Believe the clients pain is real
C- Let the client make pain management choices
PQRST Format for Assessing Pain
P- What provokes the pain?
Q- What is the quality of the pain?
R- Does the pain radiate? What causes relief?
S- What is the severity?
T- What is the timing?
Normal lab values to know:
Sodium: 135 - 145 mEq/L
Potassium: 3.5 - 5.1 mE1/L
Chloride: 98 - 107 mEq/L
Bicarbonate: 22 - 29 mEq/L
As a general rule, classes of drugs have the same generic "last" name:
"PRILS" = ACE inhibitors (enalapril, lisinopril)
"SARTANS" = angiotensin receptor blockers (losartan, valsartan)
"TRIPTANS" = treatment of acute migraine headache
"STATINS" = lower LDL cholesterol (simvastatin, rosuvastatin)
"DIPINES" = calcium channel blockers (amlodipine, nifedipine)
"PRAZOLES" = proton pump inhibitors (omeprazole)
"AZOLES" = antifungals (miconazole)
most states require LPN/VNs to observe IV sites and to report the findings to th
e RN or health care provider; observe for
leakage
clean, dry dressing
site: less than 3 days old
infection
warmth
redness
swelling
drainage
tenderness or pain
infiltration
swollen
cool to touch
infusion rate slowing or stopping phlebitis
regional pain and swelling
red streak along vein line
leakage, infiltration, or impaired infusion rate
Instilling Eye Drops
1. Wash hands and apply gloves; rinse powdery residue from gloves
2. Instruct client to recline or tilt head back
3. Instruct client to look up
4. Pull lower lid down and to the side

5. Apply drop at lower, outer aspect of eye (lower conjunctival sac)

6. Apply mild pressure to inner canthus for 1 minute to decrease systemic
absorption
7. Instruct client to gently close eyes
8. Wait 2 to 5 minutes before instilling additional eye drop (in same eye)
open ear canal
In a child younger than age 3, pull the lobe down and back
In a child older than 3 years, pull the pinna up and back
Coenzyme Q10, coral calcium, ginkgo biloba, huperzine A, omega-3 fatty acids are
being used to help with
symptoms of dementia (Alzheimers Association).
271 271 271271271271271271s
High potassium
protein sources: all meats, poultry and fish
fruits: apricots, banana , cantaloupe, honeydew, kiwi, oranges, prunes, toma
toes, raisins
vegetables: lima beans, potatoes, spinach, (baked) sweet potato with skin, a
vocado
dairy: milk , prune juice
other: sunflower seeds , molasses
Vitamin-rich foods
iron
lean red meat, liver; also clams, oysters, sardines
folic acid
green leafy vegetables, milk, eggs, liver
vitamin B12
meat, seafood, eggs, cheese
vitamin K
dark green leafy vegetables
Lipid soluble beta blocker eyedrops for glaucoma can be absorbed systemically. I
f your client states s/he is feeling "blah" or has no energy, dont assume s/he
is depressed. A CNS side effect of these drugs (timolol [Timoptic] and betaxolol
[Betoptic]) is fatigue.
O-L-D-C-A-R-T: a comprehensive assessment of clinical indicators of pain
O = Onset When did it begin?
L = Locations Where is it?
D = Duration How long does it last?
C = Characteristics What are the qualities? What is the description?
A = Attributes How did it start? What caused it?
R = Related findings What is the relationship with other things such as eating,
position changes, activity, rest?
T = Therapy & timing What effective and remedies have been tried? When does it o
ccur (time of day; before or after something else)? Any patterns?
Common Antidotes
Medication
Medication Type-Poison
Antidote
acetaminophen
N-acetylcysteine (Mucomyst, Acetadote)
most effective given within 8 hours of ingesting acetaminophen
anticholinergics
physostigmine

arsenic
chelation therapy
1) dimercaprol
2) penicillamine
3) calcium disodium edetate
4) succimer (DMSA)
benzodiazepines
flumazenil (Romazicon, Anexate)
beta blockers
(high dose) glucagon
calcium channel blockers
glucagon, calcium chloride, calcium gluconate (10%)
cholinergics
tropine, pralidoxime (2-PAM)
cyanide
amyl nitrate
sodium thiosulfate
hyperbaric oxygen chamber
digitalis/digoxin
digoxin antibodies: digoxin immune fab, DigiFab, Digibind
dnoxaparin (Lovenox)
protamine sulfate
ethylene glycol
Ethanol
fomepizole (Antizol)
pyridoxine hydrochloride (vitamin B6)
Heparin
Protamine sulfate
Hypoglycemic agents
Glucagon
octreotide (Sandostatin)
iron
deferoxamine mesylate
lead
chelation therapy:
1) dimercaprol (BAL)
2) penicillamine
3) calcium disodium edetate (CaNa2EDTA)
4) succimer (DMSA)
magnesium sulfate
calcium gluconate
mercury
helation therapy:
1) dimercaprol (BAL)
2) penicillamine
3) calcium disodium edetate (CaNa2EDTA)

4) succimer (DMSA)
methanol
folinic acid (Leucovorin) and then folic acid
fomepizole (Antizol)
mushrooms, muscarinic
atropine sulfate
nerve gas (Sarin, soman and VX)
atropine sulfate
pralidoxime chloride
2-PAM Cl, Protopam)
opioids (codeine, morphine)
Naloxone (narcan), nalmefene
snakes (rattlesnakes, copperheads, cottonmouths)
Antivenin (Crotalidae)
Polyvalent (equine origin)
Crotalidae Polyvalent Immune Fab (Ovine)
spiders (black widow)
Antivenin (Latrodectus mactans), equine
tricyclic antidepressants
sodium bicarbonate
vasopressor infiltration and extravasation
phentolamine mesylate (Regitine)
warfarin
phytonadione (vitamin K)
(Hypernatremia) Serum Na+ level > 145 mEq/L
Thirst, elevated temperature, dry mucous membranes, oliguria, hyperreflexia; inf
ants exhibit depressed
fontanelles and irritability
(Hyponatremia) Serum Na+ level < 135 mEq/L
Nausea and vomiting; headache; confusion; lethargy; fatigue; appetite loss, rest
lessness and irritability; muscle
weakness, spasms or cramps; seizures; decreased consciousness or coma
(Hyperkalemia) Serum K+ level > 5 mEq/L
Client may experience irregular heartbeat; nausea; bradycardia; EKG changes incl
ude peaked T wave and
depressed P wave, wide QRS complex
(Hypokalemia) Serum K+ level < 3.5 mEq/L
Muscle weakness, aches and cramps; tetany; hypotension; constipation; arrhythmia
s
(Hypercalcemia) Serum calcium level > 10.2 mg/dL
Constipation, anorexia, nausea, abdominal pain, muscle twitches and weakness, de
mentia, irritability
(Hypocalcemia) Serum calcium level < 8.2 mg/dL

Seizures; extrapyramidal symptoms; papilledema; muscle stiffness, myalgias, spas

ms; positive Chvosteks and Trousseaus sign; prolongation of QT interval; diaph
oresis
(Hypermagnesemia) Serum magnesium level > 2.1 mEq/L
Uncommon -Usually associated with increased intake; prolonged PR interval and wi
dened QRS; hyporeflexia, hypotension, respiratory depression and cardiac arrest
(Hypomagnesemia) Serum magnesium level < 1.4 mEq/L
Anorexia, nausea, lethargy, weakness, tetany, positive Trousseaus or Chvosteks sig
n, fasciculations, tremor; usually accompanies hypokalemia and hypocalcemia
(Hyperphosphatemia) Serum phosphorus level > 4.1 mg/dL
Usually asymptomatic; similar to hypocalcemia
(Hypophosphatemia) Serum phosphorus level < 2.4 mg/dL
Usually asymptomatic; anorexia, muscle weakness, osteomalacia
Normal Adult Electrolyte Values
Electrolyte
Value (milliequivalents per liter or mEq/L)
Sodium 135 - 145 mEq/L
Potassium
3.5 - 5.1 mE1/L
Chloride
98 - 107 mEq/L
Bicarbonate (venous)
22 - 29 mEq/L
Care of the client in T-R-A-C-T-I-O-N:
Temperature (extremities, infection)
Ropes hang freely
Alignment
Circulation check (the 5 Ps)
Type & location of fracture
Increase fluid intake
Overbed trapeze
No weight(s) on bed or floor
For client to navigate stairs with crutches, remember:
"Up with the Good, Down with the Bad."
To go up stairs, lead with the unaffected or "good" leg, and follow with the affe
cted "bad" leg.
To go down stairs, lead with the affected or "bad" leg, and follow with the unaff
ected "good" leg.
Postoperative period - postanesthesia care unit (PACU) nursing intervaentions
Care Category
Interventions
Maintain
PATIENT AIRWAY
Maintain
Respiratory effort, rate, rhythm, and depth
Stabilize vital signs
Position
Position client on side (unless contraindicated) or on back with head to side
Keep side rails up at all times with bed in lowest position (if possible)
Provide
For client physical and psychological safety
Oxygen as ordered
Administer pain medication as ordered
Stimulate
Ask client to spit out airway (shows gag reflex is back) and to lift head off pi
llow
Facilitate elimination of residual anesthesia, indicates ability to clear airway

Stimulate client to take a few deep breaths every 5 to 10 minutes

Stay
Check vital signs every 15 minutes until stable, then every 30 minutes or as ord
ered
Stay with restless client
Determine if restlessness is due to hypoxia
recovery complications and how to react
Complication
Reaction 1
Reaction 2
Reaction 3
Reaction 4
Hypothermia*
Apply warmed blankets;
always keep client covered
Increase temperature of recovery room
Change method of
assessing Temp and
compare results
Hemorrhage
dressing for intactness
any dependent
area of the dressing,
e.g., behind client, and on bed for drainage, blood pooling
all drainage tubes and note color and amount of drainage
for internal
bleeding, looking for
tautness or distention at abdomen or incision site
Hypotension
Give IV fluids as ordered
Monitor HR and
blood pressure
Auscultate lungs
Elevate legs as
ordered
*Note: shivering may result from certain anesthetics and is not always indicativ
e of hypothermia
REMEMBER IT
This might help you to remember the names and location of the heart valves:
Tiny right side of the heart = Tricuspid valve
Mighty (or Big) left side of the heart = Mitral (or Bicuspid) valve
Leukocytes (white blood cells) increase with infections or inflammation:
Leukocyte
Type
Increases in Response to
Neutrophil
Granulocyte
Infection by bacteria or fungus
Lymphocyte
Agranulocyte
Viral infection or tumor
Eosinophil
Granulocyte
Inflammation from allergies
Basophil

Granulocyte
Inflammation from allergies
Monocyte
Agranulocyte
Infections - nonspecific
THE "CARDIO FIVE" TEACHING PLAN
TDDDS
Topic
Nursing Action
T
Tests and Treatments
Explain tests and treatments in simple, culturally sensitive ways
D
Drugs
Write out names and explain reason for drugs, their side effects, and how long c
lient will take them
D
Diet
Good nutrition and restrictions, i.e., low sodium diet, reduce cholesterol level
s
D
Disease
Explanation of the disorder and treatment plan
S
Smoker?
Encourage to stop smoking
abnormal heart sounds : murmur, S3 or gallop or friction rub
Management for symptomatic mitral stenosis - use the DO-ABLE mnemonic
D = diuretics - to relieve pulmonary congestion, fluid overload & return to base
line weight
O = oxygen - to correct hypoxia
A = ACE inhibitors- to reduce preload and afterload, counteracting compensatory
hormones
B = beta-blockers - to prevent arrhythmias and reduce heart workload
L = low sodium diet - to prevent fluid retention
E = exercise as tolerated - to monitor response to therapy and return to baselin
e functional status
g. surgery - mitral valve repair or replacement for severe or recurrent episodes
of heart failure
Self-care instructions for heart failure: R-E-A-L keys
R=eport findings of heart failure to provider - weight gain, worsening dyspnea,
orthopnea, fatigue
E=xercise is important - start low & go slow to increase functional capacity, at
tending to symptoms
A=dherence to cardiac medications is essential to staying healthy
L=ow sodium diet - 2000 grams per day
CARDIAc LeVeLS assessment for heart failure symptoms and complications
C = chest discomfort
A = activity tolerance
R = response to drug therapy
D = depression and anxiety
I = increased weight
A = arrhythmias
L = lightheadedness
V = vital sign - changes

L = level of consciousness - decreased

S = shortness of breath
Treatment for pulmonary edema: M DOG
M= Morphine
D= Diuretics (furosemide)
O= Oxygen
G= Gases (blood gasses)
Therapeutic treatment for Myocardial infarction: "O BATMAN!"
O=Oxygen
B=Beta blocker
A=ASA (aspirin)
T=Thrombolytics (heparin)
M=Morphine
A=ACE (especially for those with heart failure or a lower ejection fraction)
N=Nitroglycerin
Heart Failure symptoms listed in order of earliest to later findings
Right Left
Significant weight gain Fatigue and activity intolerance
Jugular vein distention
Bilateral dependent peripheral edema
Liver engorgement (hepatomegaly with abdominal pain, anorexia, and nausea)
Ascites
Fatigue and activity intolerance
Cough (often dry initially)
Mild weight gain that leads to early pulmonary symptoms
Shortness of breath/orthopnea
Paroxysmal nocturnal dyspnea
Tachypnea
Crackles
S3 heart sound
Cardiac cachexia and muscle weakness in advanced stage
Acute pulmonary edema:
Frothy sputum (may be blood-tinged)
Restlessness, irritability, hostility, agitation, anxiety
Prominent crackles throughout lung fields
Diaphoresis
Cyanosis
classic triad of signs
a. hypotension with
b. muffled heart sounds with
c. marked jugular vein distention if no hypovolemia
Clinical practice guidelines indicate that individuals with a systolic blood pre
ssure of 120139 mm Hg or a diastolic blood pressure of 8089 mm Hg should be consid
ered as "prehypertensive" and will require health-promoting lifestyle modificati
ons to prevent cardiovascular disease (National Heart Lung and Blood Institute,
2003).
Complementary and Alternative Medicine
Garlic, ginseng dried root, hawthorn, and snakeroot have been used to treat hype
rtension; however, theres not
enough research to support the efficacy and safety of these herbal therapies.
Supplements:
Coenzyme Q10 (CoQ10) supplements may cause small decreases in blood pressure; lo

w blood levels of CoQ10

have been found in people with hypertension
Omega-3 fatty acids supplements may lower blood pressure
Amino acid L-arginine diet supplements may temporarily lower blood pressure
Alternative systems of care
Traditional Chinese medicine
Avurveda
Note: Licorice and ephedra should not be used by people with hypertension becaus
e they can increase blood
pressure.
Management of atrial fibrillation: ABCD
A=Anticoagulant
B=Beta blocker to control rate
C=Cardioversion (if beta blocker ineffective or calcium channel blocker to contr
ol rate)
D=Digoxin
6 Ps of acute arterial occlusion:
Pallor (or mottling)
Pain
Paresthesia (numbness or tingling)
Pallor (cool or cold skin)
Pulselessness (distal to the blockage)
Paralysis (or weakness or muscle spasm)
Remember Acid-Base lab interpretation using - R.O.M.E.
R=Respiratory
O=Opposite
M=Metabolic
E=Equal
respiratory acidosis*
(< 7.35)
(> 26)
(> 45)
increased renal acid excretion
respiratory alkalosis
(> 7.45)
(> 26)
(> 45)
decreased renal acid excretion
metabolic acidosis
(< 7.35)
(< 22)
(< 35)
hyperventilate
metabolic alkalosis
(> 7.45)
(> 26)
(> 45)
hypoventilate

To remember the classic findings of Parkinsons disease think:

T-R-A-P
T= tremors
R= rigidity
A= akinesia/bradykinesia
P= postural instability

To help remember PUD treatment, use this phrase:

"Please Make Tummy Better"
P= Proton pump inhibitor
M= Metronidazole
T= Tetracycline
B= Bismuth subsalicylate
Dont
Ileum
Ileus
Ilium

confuse these three!

= most distal part of the small intestine
= an obstruction (often in an intestine)
= part of the hipbone

The 6 Fs for gallbladder disease:

Fair (skin and hair)
Fat
Forty (and older)
Fertile (lots of children)
Female
Flatulent
Antihypertensives may cause orthostatic (postural) hypotension. Remember to teac
h clients to change "postures" slowly to prevent "postural" hypotension. Men tak
ing medications for erectile dysfunction are at greater risk.
Dont be confused by these terms! Cystocele is a hernia (the bladder drops into
the vagina), but endometriosis can lead to cyst formation outside the uterus.
ENDOCRINE
Adrenal gland (cortex) hormones - SSS
S=Sugar (glucocorticoids)
S=Salt (mineralocorticoids)
S=Sex (androgens)

To help remember the glands of the endocrine system, remember: "Herman Probably
Pasted The Paper To A Pot Of Tea"
H=Hypothalamus
P=Pituitary
P=Pineal
T=Thyroid
P=Parathyroid
T=Thymus
A=Adrenal
P=Pancreas
O=Ovaries
T=Testes
S/of hyperparathyroidism can be remembered as: "moans, groans, stones, and bones
... with psychic overtones."
When reading the stem of the question, give special attention to words such as:
BEST, MOST, LEAST, FIRST, PRIORITY, INITIAL
Although its extremely oversimplified, think of the relationship between insuli
n and glucose as a see-saw. When one is higher, the other tends to be lower.
Nursing Care for sprains and strains: RICE
R= Rest
I= Ice
C= Compression
E= Elevation
apply cold to minimize edema
The 5 Ps of circulation checks:
P=Pain
P=Paresthesia
P=Paralysis
P=Pulse
P=Pallor (Paleness)

Carefully read each multiple-choice question to looking for key concepts that ar
e familiar to you. Try rephrasing the question, but do NOT read anything into it
.
For client to navigate stairs with crutches, remember:
"Up with the Good, Down with the Bad."
To go up stairs, lead with the unaffected or "good" leg, and follow with the affe
cted "bad" leg.
To go down stairs, lead with the affected or "bad" leg, and follow with the unaff
ected "good" leg.

ONCOLGY

CANCER Interventions:

C=Comfort
A=Altered body image
N=Nutrition
C=Chemotherapy
E=Evaluate response to medications
R=Respite for caretakers

Age appropriate diversional activities:

Toddler
washable soft toys, appropriate cartoons, action toys (wagon, push toys)
Kindergarten
appropriate cartoons, washable stuffed doll, coloring books and crayons, action
toys
School -age
appropriate cartoons or video games, coloring book and crayons, school work when
appropriate, computer, beads for creating jewelry
Middle - School
computer or cell phone, appropriate video games, school work when appropriate
High -School
computer or cell phone, appropriate video games, school work when appropriate
Children, particularly toddlers and pre-schoolers, tend to have bruises as a res
ult of play. Any unusual bruising -on the back or neck, large or dark bruises- n
eeds to be checked out. It could be the first sign of leukemia or it could possi
bly due to child abuse. If you are unsure, be sure that another nurse checks the
child with you.
Look Good... Feel Better is dedicated to improving the self-esteem and quality o
f life of people undergoing treatment for cancer.
Types of shock are classified according to etiology: CHANS
Cardiogenic - caused by inability of the heart to pump blood effectively (due to
heart attack or heart failure)
Hypovolemic - caused by inadequate blood volume (due to bleeding or dehydration)
Anaphylactic - caused by allergic reaction
Neurogenic - caused by damage to nervous system (due to extreme emotional upset
due to personal tragedy or disaster)
Septic - caused by systemic infection

Aplication
Nursing Action
Rationale
A
Activities of daily living
(ADLs)
Help the client with ADLs
it stresses the heart less
B
Bed rest
Maintain bed rest
it reduces the oxygen demands on the heart
C
Commode

Commode at bedside
it stresses the heart less than using a
bedpan
D
Diversions
Offer diversionary activities while on bedrest
offer diversions that dont stress the heart
E
Elevate
Elevate head of bed (semiFowlers) or sit client up
to increase chest expansion and improve ventilation
F
Feelings
Listen to clients concerns; provide emotional support to reduce anxiety
anxiety increases oxygen demand
THE TRAUMA CLIENT
Assessment and early management of the trauma client includes the following:
Emergency trauma assessment: ABCDEFGHI
Primary Assessment = A, B, C, D & E
Secondary Assessment = F, G, H & I
Remember A-I mnemonic for trauma clients:
A=Airway with simultaneous cervical spine protection
B=Breathing
C=Circulation
D=Disability (neurologic status)
E=Exposure/environmental controls
F=Full set of vital signs/focused adjuncts/family presence
G=Give comfort measures
H=History and Head to toe assessment
I=Inspect posterior surfaces
Primary
A =
zation
B =
C =

survey: ABCs
airway maintenance with spinal cored control, i.e., cervical stabili
breathing
circulation

For the initial assessment - use the AVPU mnemonic:

A=Alert - Speak to the client; a client who is alert and responsive is considere
d "A" (for "alert")
V=Verbal - The client who responds to verbal stimuli is considered "V" (for "ver
bal")
P=Pain - Apply a painful stimulus; a client who does not respond to a verbal sti
muli but does respond to a painful stimulus is considered "P" (for "pain")
U=Unresponsive - The client who does not respond to a painful stimulus is consid
ered "U" (unresponsive)
CPR
Compressions - Airway - Breathing ("C-A-B")
Complications of a trauma client: TRAUMATIC
T=Tissue perfusion problems
R=Respiratory problems
A=Anxiety
U=Unstable clotting factors
M=Malnutrition
A=Altered body image

T=Thromboembolism
I=Infection
C=Coping problems
PEDS
Cyanotic defects - the 4 Ts:
T=Tetralogy of fallot
T=Truncus arteriosus
T=Transportation of the great vessels
T=Tricuspid atresia
When assessing diarrhea or constipation, remember the acronym ACCT:
A= amount
C= color
C= consistency
T= time (duration)
Associate Hirschsprungs with a girl ("her") who wears "ribbons" in her hair - t
o recall that "ribbon-like"
stools are a classic finding of this disease.
Newborns skin is thinner, more easily hurt by endotoxins and tearing forces
Childs body absorbs more of topical products
Harder to regulate body temperature