TABLE OF CONTENTS Basic Care

Activities of Daily Living (ADL’s)..............................................................................................................................................1 Instrumental Activities of Daily Living (IADL’s)................................................................................................................ 2 Four C’s of Initial Direction..................................................................................................................................................... 3 Bleeding Precautions............................................................................................................................................................... 4 Blood Pressure........................................................................................................................................................................... 5 Range of Motion........................................................................................................................................................................6 Canes and Walkers.....................................................................................................................................................................7 Transfusion Reactions.............................................................................................................................................................8 Types of Exudate....................................................................................................................................................................... 9 Immune System Response....................................................................................................................................................10 Analgesia vs Anesthesia......................................................................................................................................................... 11 Autonomic Nervous System Response.............................................................................................................................12 Is it a Cold or the Flu?............................................................................................................................................................13 Special Considerations for Older Adults..........................................................................................................................14 Normal Elimination...................................................................................................................................................................15 Heat and Cold Applications................................................................................................................................................. 16 Hand Hygiene............................................................................................................................................................................. 17 Informatics.................................................................................................................................................................................18

Assessment

Tools of Physical Assessment.............................................................................................................................................19 Trauma Survey (After Initial Assessment).................................................................................................................... 20 6 P’s of Dyspnea......................................................................................................................................................................21 Lung Sounds.............................................................................................................................................................................22 Reasons for Unconsciousness........................................................................................................................................... 23 Levels of Consciousness.......................................................................................................................................................24 Shock..........................................................................................................................................................................................25 Neurovascular Assessment................................................................................................................................................ 26 Five Areas for Listening to the Heart.............................................................................................................................. 27 Auscultation of Heart Sounds.......................................................................................................................................... 28 Heart Sounds.......................................................................................................................................................................... 29 Prioritization and Delegation.............................................................................................................................................. 30

Fluids, Acid-Base and Electrolytes

Basics of Hydration................................................................................................................................................................31 Top 5 Fluids...............................................................................................................................................................................32 Acidosis - Allkalosis.............................................................................................................................................................. 33 Causes of Alkalosis............................................................................................................................................................... 34 Causes of Acidosis................................................................................................................................................................ 35



iv



Memory Notebook of Nursing, Vol. 2, 4th ed.

© 2012 Nursing Education Consultants, Inc.

Hyperkalemia...........................................................................................................................................................................36 Potassium Deficit....................................................................................................................................................................37 Calcium-Phosphorus Relationship..................................................................................................................................... 38 Heat Exhaustion.................................................................................................................................................................... 39 Heat Stroke............................................................................................................................................................................. 40

Pharmacology

Administration of Medications by Inhalation..................................................................................................................41 Transdermal Medication Administration .......................................................................................................................42 Guide to Drug Overdose....................................................................................................................................................... 43 Salicylate Poisoning............................................................................................................................................................... 44 Lidocaine Toxicity.................................................................................................................................................................... 45 Toxic Levels - Lithium, Digoxin, Theophylline....................................................................................................................46 Aminoglycoside Toxicity......................................................................................................................................................... 47 Peak and Trough (Antibiotics)............................................................................................................................................. 48 Serious Complications of Oral Birth Control Pills........................................................................................................ 49 Emergency Drugs................................................................................................................................................................... 50 Beta-1 and Beta-2 Blockers..................................................................................................................................................51 Drugs for Bradycardia and Low Blood Pressure............................................................................................................52 Anti-Hypertensive Drugs..................................................................................................................................................... 53 Anti-Cancer Drugs - Adverse Reactions/Precautions................................................................................................ 54 Cholinergic Crisis..................................................................................................................................................................... 55 Mixing Insulin............................................................................................................................................................................ 56 Heparin and Coumadin...........................................................................................................................................................57 MAO Inhibitors........................................................................................................................................................................ 58 Anti-Inflammatory (Corticosteroids).............................................................................................................................. 59 B6 - Isoniazid and Levodopa................................................................................................................................................60 Insulin Pregnancy Requirements..........................................................................................................................................61

Psychosocial

Psychiatric Assessment...................................................................................................................................................... 62 Depression Assessment......................................................................................................................................................63 Stress Reduction Methods................................................................................................................................................64 5 A’s to Alzheimer’s Diagnosis........................................................................................................................................... 65 Sundowning Syndrome.........................................................................................................................................................66 Anorexia Nervosa....................................................................................................................................................................67 Bulimia.......................................................................................................................................................................................68 Child Abuse...............................................................................................................................................................................69 Obsessive-Compulsive Disorder...........................................................................................................................................70 Manic Attack - Primary Symptoms................................................................................................................................... 71 Cocaine/Crack Users.............................................................................................................................................................. 72 Dementia....................................................................................................................................................................................73

© 2012 Nursing Education Consultants, Inc.

Memory Notebook of Nursing, Vol. 2, 4th ed. v

Immune

Systemic Lupus Erythematosus (SLE)........................................................................................................................... 74 Anaphylactic Reaction..........................................................................................................................................................75 AIDS............................................................................................................................................................................................76

Sensory

Refractive Errors.................................................................................................................................................................... 77 3 P’s of Blindness...................................................................................................................................................................78 Glaucoma..................................................................................................................................................................................79 Corneal Transplant Surgery................................................................................................................................................80 Otitis Media...............................................................................................................................................................................81

Hematology

Sickle Cell Anemia Crisis....................................................................................................................................................... 82 Hemophilia................................................................................................................................................................................ 83 Symptoms of Leukemia (ANT)........................................................................................................................................... 84

Endocrine

Type 2 Diabetes...................................................................................................................................................................... 85 Hypoglycemia...........................................................................................................................................................................86 Diabetic Ketoacidosis............................................................................................................................................................87 Exercise Guide for Diabetic Fitness.................................................................................................................................88 Hyperpituitary-Acromegaly................................................................................................................................................. 89

Respiratory

Symptoms of Hypoxia..........................................................................................................................................................90 Respiratory Patterns.............................................................................................................................................................91 Management of Asthma...................................................................................................................................................... 92 Pneumothorax......................................................................................................................................................................... 93 Pneumonia................................................................................................................................................................................ 94 Acute Respiratory Distress Syndrome (ARDS)........................................................................................................... 95 Cystic Fibrosis (CF)...............................................................................................................................................................96 Guidelines for PPD’s...............................................................................................................................................................97 Pulmonary Embolus................................................................................................................................................................ 98 Epiglottitis............................................................................................................................................................................... 99

Cardiac

Head to Toe Cardiac Clues.................................................................................................................................................100 Blood Flow Through the Cardiac Valves........................................................................................................................... 101 Heart Murmurs......................................................................................................................................................................102 Pulmonary Artery Catheter..............................................................................................................................................103 Cardiac Output......................................................................................................................................................................104 Lead II Placement..................................................................................................................................................................105 Cardioversion/Defibrillation............................................................................................................................................... 106



vi



Memory Notebook of Nursing, Vol. 2, 4th ed.

© 2012 Nursing Education Consultants, Inc.

Myocardial Infarction - 3 Areas of Damage................................................................................................................. 107 Immediate Treatment of an Myocardial Infarction.....................................................................................................108 Treating Congestive Heart Failure...................................................................................................................................109

Gastrointestinal

Appendicitis............................................................................................................................................................................. 110 Bowel Obstruction...................................................................................................................................................................111 Dumping Syndrome.................................................................................................................................................................112 Sir Hernia.................................................................................................................................................................................. 113 Peritonitis................................................................................................................................................................................. 114

Liver

Hepatitis................................................................................................................................................................................... 115

Neurology

Posturing.................................................................................................................................................................................. 116 Paralysis.....................................................................................................................................................................................117 Stroke Recognition................................................................................................................................................................ 118 CVA - Functioning vs Affected........................................................................................................................................... 119 Right CVA.................................................................................................................................................................................120 Left CVA.....................................................................................................................................................................................121 Spinal Cord Injury.................................................................................................................................................................. 122 Levels of Spinal Nerves........................................................................................................................................................ 123 Autonomic Dysreflexia......................................................................................................................................................... 124 Warning Signs After a Head Injury.................................................................................................................................. 125 Duchenne’s Muscular Dystrophy......................................................................................................................................126 Multiple Sclerosis...................................................................................................................................................................127 Guillain-Barré Syndrome.....................................................................................................................................................128 Tetanus.................................................................................................................................................................................... 129 Seizures...................................................................................................................................................................................130

Musculoskeletal

Osteoporosis........................................................................................................................................................................... 131 Osteoporosis Risk Factors................................................................................................................................................ 132 Crutch-Walking Up Stairs...................................................................................................................................................133 Hip Fracture............................................................................................................................................................................134 Post-Op Care - Hip Fractures...........................................................................................................................................135

Renal

Glomerulonephritis...............................................................................................................................................................136 Preventing Cystitis................................................................................................................................................................137 Post Kidney Transplant Rejection Signs........................................................................................................................138 Renal Compensation in Shock...........................................................................................................................................139 Who Needs Dialysis?.............................................................................................................................................................140

© 2012 Nursing Education Consultants, Inc.

Memory Notebook of Nursing, Vol. 2, 4th ed. vii

Reproductive

Prostate Problems ................................................................................................................................................................141

Integumentary

Malignant Melanoma............................................................................................................................................................ 142 Depth of Burns...................................................................................................................................................................... 143 Degree of Burn by Tissue Layer........................................................................................................................................144 Tips on Healing Skin Lesions..............................................................................................................................................145 Rocky Mountain Spotted Fever........................................................................................................................................146 Lyme Disease...........................................................................................................................................................................147 Kawasaki Syndrome.............................................................................................................................................................148

Vascular

Peripheral Vascular Disease - Venous vs Arterial Ulcers..........................................................................................149

Maternity and Newborn

Journey to Delivery .............................................................................................................................................................150 Clue to Contractions............................................................................................................................................................ 151 Fetal Station.......................................................................................................................................................................... 152 Early and Late Decelerations............................................................................................................................................153 Plus 4 Station and Delivery...............................................................................................................................................154 Post Partum Complications...............................................................................................................................................155 Phenylketonuria (PKU).........................................................................................................................................................156 Caput Succedaneum.............................................................................................................................................................157 Umbilical Cord Vessels..........................................................................................................................................................158 Index..................................................................................................................................................................................159-162



viii



Memory Notebook of Nursing, Vol. 2, 4th ed.

© 2012 Nursing Education Consultants, Inc.

ACTIVITIES OF DAILY LIVING

ADLs = BATTED (Activities of Daily Living)

Toileting

Bathing Ambulation

Eating ©Nursing Education Consultants, Inc.

Transfers © 2012 Nursing Education Consultants, Inc.

Dressing Basic Care NursingEd.com 1

BLEEDING PRECAUTIONS RazorElectric

Aspirin

Aspirin - NO! Needles Small Gauge Decrease Needle Sticks

#22 Needle

Observe For:

n tio e Cau Pleas

Injury Protect From

R A N D I

Please limit needle sticks

IMPLEMENT WHEN:

Using anticoagulants ● Liver disease present ● Platelets 150,000 ● Hemophilia present ● Using thrombolytic meds ●

Gingival Bleeding Hematuria Melena Bruising Nosebleeds

©Nursing Education Consultants, Inc.



4



Basic Care NursingEd.com

© 2012 Nursing Education Consultants, Inc.