Molecule of the Day: VX

VX (C11H26NO2PS) is a colourless, odourless, oily liquid under room temperatures. It is a member of the V-series of nerve agents, and is an extremely potent poison - only 0.01 grams of it is needed to kill a person by skin contact. VX was recently implicated in the assassination of Kim Jong-nam, the half-brother of the North Korean leader Kim Jong-un, in Malaysia.

VX is a potent inhibitor of acetylcholinesterase, which breaks down the neurotransmitter acetylcholine into acetic acid and choline. The normal function of the enzyme is to regulate the concentration of acetylcholine within the synaptic cleft, so as to control the frequency of binding of acetylcholine to cholinergic receptors on the postsynaptic cell membrane and hence the transmission of impulses across the synapse.

Consequently, the inhibition of acetylcholinesterase results in a rapid increase in the synaptic concentration of acetylcholine, as the presynaptic knob continues to synthesise it and secrete it into the synaptic cleft. As a result, the cholinergic receptors on the postsynaptic cell membrane are continually stimulated, and a rapid series of action potentials are triggered. This results in muscle spasms and eventual paralysis, leading to death by asphyxiation due to paralysis of the diaphragm.

VX exposure is usually treated using an injection of atropine and pralidoxime. Atropine inhibits certain cholinergic receptors, reducing the binding of acetylcholine to receptors and thus the triggering of action potentials. On the other hand, one end of pralidoxime binds to acetylcholinesterase and the other binds to the phosphate group of VX, which causes the VX molecule to detach from the enzyme together with the pralidoxime molecule (see below). This restores the ability of acetylcholinesterase to hydrolyse acetylcholine, hence reducing its synaptic levels.

VX is synthesised from phosphorus trichloride over multiple steps; first, it is methylated, reacted with ethanol, then transesterified with N,N-diisopropylaminoethanol to produce QL. This is then oxidised with sulfur, and isomerised via heating to produce VX.

Regulation of Digestion

All aspects of the GI processes are controlled by neural, hormonal and paracrine controls, specific control systems include

  •  Long & Short Reflexes 
  • GI peptide reflexes 
  • The autonomous function of the enteric nervous system (ENS) 

Long Reflexes 

  • Integrated within in the CNS 
  • May originate in or outside of the GI tract 
  • Feedforward & emotional reflexes are initiated and integrated entirely outside the GI tract 
  • Called cephalic reflexes 

Short Reflexes 

  • Integrated in the enteric nervous system
  • Initiated by changes in pH, distension, osmolarity, products of digestion 
  • Submucosal plexus contains the sensory neurons 
  • Afferent information to ganglia 
  • Efferent information to submucosal and myenteric plexuses for control of secretion, motility and growth 

GI Peptide Reflexes 

Peptides released by the GI tract may act: 

  • as hormones 
  • Secreted into the blood 
  • Act on accessory organs, other parts of the GI tract or the brain 
  • As paracrine signals 
  • Secreted into the lumen or extracellular fluid 
  • Lumenal signals bind to apical epithelial receptors 
  • ECF signals act in the immediate vicinity of secretion 


  • Peptides alter secretion and motility 
  • Alter behaviour related to eating 

Enteric Nervous System 

  • Allows for the autonomous behaviour of the digestive system 
  • CNS control is not required for digestive functioning 

Commonalities between ENS and CNS:

  •  Intrinsic neurons – similar to interneurons of CNS 
  • Extrinsic neurons – composed of autonomic neurons 
  • Neurotransmitters and neuropeptides 
  • Nonadrenergic and noncholinergic receptors - same as adrenergic and cholinergic in CNS 
  • Glial support cells – similar to astrocytes in CNS 
  • Diffusion barrier – cells around capillaries in the ganglia are tight, just as the capillaries in the brain, forming the BBB 
  • ENS acts as its own integrating centre, just as the CNS does 

Cephalic phase

  • Stimulus-CNS-Vagus nerve-ANSSalivary glands-salivary amylase & lingual lipase 
  • Enteric Nervous system-increased gastric secretions and motility 

Gastric phase  

  • Stores food; digests into chyme 
  • Protects (mucus and HCl)

Intestinal phase

  • Digestion of proteins, formation of chime in ileum 
  • Controlled entry of chyme into ileum 
  • Concentration of waste and digestion in colon 

majahawt  asked:

Hey, I don't know if you've covered this before but are there any details on what specifically in marijuana that's harmful for reptiles/what it does? Even without the smoke, just the substances. I've... Got a guy talking about feeding cannabis plants to iguanas

Yeah, the substance itself is actually quite toxic! There’s been a few studies done on marijuana toxicity, but most of them refer to the smoke. There’s a few other citations, but the best comprehensive thing I know of is from this vet textbook called Reptile Medicine and Surgery. The second edition’s fairly recent (within the past decade) and everything that’s come out after typically refers to this book and the stuff cited within. (Side note: This book is an excellent resource and honestly quite worth signing up for the free Scribd trial just to download and have on hand. For most reptile owners, the detailed vet procedure stuff won’t be as useful, but the pictures and stuff about common diseases and how they present is invaluable.)

Here’s what the book’s got to say about marijuana toxicity and what it does to reptiles:

Marijuana continues to be by far the most used illicit drug in the United States. Cannabis sativa has been used for centuries for its hemp fiber, as rope, and for its psychoactive resins. Totally or partially herbivorous captive reptiles may encounter growing marijuana plants or ingest dried stems, leaves, and flowers. The main active ingredient of marijuana is tetrahydrocannibinol (THC). The highest concentration of this psychoactive constituent is found in the leaves and the flowering tops of plants. Hashish is the dried resin of flower tops. The precise mechanism of action of THC is unknown, but the psychoactive effects of this drug are thought to stem from a number of sites within the CNS, including cholinergic dopaminergic, serotonergic, noradrenergic, and GABA receptors. Ingested marijuana shows effects much more slowly than the results of the inhaled smoke; however, the effects of ingested THC last much longer. Clinical signs after ingestion of marijuana include mydriasis, weakness, ataxia, bradycardia, hypothermia, and stupor. The extent of clinical signs after marijuana ingestion is almost totally dose related. Treatment for marijuana ingestion is primarily supportive and symptomatic. Marijuana toxications are rarely fatal because of the wide margin of safety of THC. Activated charcoal administration is recommended to decrease enterohepatic recirculation. Despite its relative safety margin, recovery after ingestion may be prolonged and take up to 3 to 4 days. Fluids and monitoring of body temperature may be beneficial. We have seen two reptiles ingest fairly large amounts of marijuana. A 10-pound Sulcata Tortoise showed no effects after eating four marijuana cigarettes. However, a 6-pound male Green Iguana was stuporous after eating into a “baggie” of marijuana and needed support. Both animals recovered completely. Undoubtedly other “under-the-counter” drugs have been blundered across by reptiles. Various “over-the-counter” drugs kept on nightstands, kitchen counters, or bathroom shelves may be encountered by captive reptiles given free range in the house. For their own safety, captive animals should be confined and all medications kept in their original containers in child-proof and animal-proof cabinets.

So yes, it’s toxic. Do the animals usually die from eating it? Well, no, because the plant itself is relatively safe. Is it a good idea? Absolutely not, why would you put your animal through that??

Autonomic system drugs mnemonic

Please give some tips on remembering cholinergic and adrenergic drugs.

Drugs ending in

- ine are beta agonists
(Terbutaline, ritrodine)

-sin are alpha blockers
(Prazosin, terazosin)

- olol are beta blockers
(Propanolol, metoprolol)

- alol are alpha + beta blockers (Labetalol)

- stigmine are cholinergic drugs
(Neostigmine, physiostigmine)

lucys-imaginarium  asked:

What are some of your favourite med school mnemonics? (5 weeks out from finals haha)

I was a big fan of the shortcut way to draw the brachial plexus, though I don’t remember it perfectly now. Unfortunately I remember more mnemonics than what they’re supposed to stand for. 

Other faves include:

  • Learn one. The other one’s the other one. - Goljan’s wise advice on learning the difference between 2 things. This is how I distinguish pemphigus and pemphigoid. 
  • the R-rated version of the cranial nerves. I’ll just abbreviate OOOTTAFVGVAH. I still run through that one. 
  • Some Say Marry Money But My Brother Says Big Boobs Matter More (remembering which cranial nerves are sensory, motor, or both)
  • I remember on renal drawing Hydrogen and potassium ions on a seesaw to remember how they moved in relationship to each other
  • There was definitely a weird one to remember the glycogen storage diseases, but I’ve never had to use that one so I’ve forgotten.
  • SpIN and SnOUT - for specificity and sensitivity, which rules in and which rules out
  • SIG E CAPS - symptoms of depression - Sleep disturbance, loss of Interest, Guilt, loss of Energy, poor Concentration, Anhedonia, Psychomotor retardation, Suicidality
  • MUDPILES - things that cause anion gap metabolic acidosis
  • DUMBBELS - cholinergic overdose symptoms - Diarrhea, Urination, Miosis, Bronchorrhea, Bradycardia, Emesis, Lacrimation, Sweating/Salivation
  • DIAPPERS - causes of urinary incontinence - Delirium, Infection, Atrophic Vaginitis, Pharmaceuticals, Psych, Excessive urine output, Reduced mobility, Stool impaction
  • Dry as a bone, hot as hades, blind as a bat, red as a beet, mad as a hatter - effects of anticholinergic drugs
  • wet, wacky, wobbly - symptoms of normal pressure hydrocephalus
  • bones, groans, stones, and psychic moans- symptoms of hypercalcemia
  • VEAL CHOP - fetal monitoring (put the words on top of each other)- Variable = Cord compression; Early Decel = Head compression; Acceleration = O2; Late Decel = Placental insufficiency
  • social history on kids and teenagers: HEADDSSS - Home, Education, Activities, Drugs, Depression, Safety, Sex, Suicide

Source: Atropa belladonna,also knon as deadly nightshade. Devil’s cherries. Devil’s herb, and dwale. 

Form: The whole plant is poisonous, but especially the berries.

Antidote(s): No specific antidote, by physostigmine may be used to counteract some effects. 

Overview: Belladonna is the name given both to a plant and to the preparation that can be made from its berries, leaves, and roots. The shiny red erries are the parts most likely to be accidentally consumed, particularly by children. Belladonna and related plants such as datura, henbane, and mandrake, are rich in belladonna alkalouids, which include atropine, hyoscamine and scopolamine. Deadly nightshade is rich in atropine, which has an anti-cholinergic effect, meaning that it blocks the action of acetylcholine, especially at neuromuscular synapses of the parasympathetic system- the part of the nervous system that inhibits the action of the heart and stimulates the digestive system. As a result, atropine inhibits digestion and stimulates heart action. The name derives from the practice of using drops of belladonna preparation to dilate the pupils- seen as an essential attribute of female beauty, hence, “belladonna” or “beautiful woman.”

Symptoms: Characteristic symptoms of belladonna poisoning are loss of voice and loss of movement of the hands and fingers. In small doses atropine can be used to halt stomach or gut spasms, dilate pupils, and speed up the heart. In toxic doses it causes extreme dryness of the mouth and throat, urinary retention, and racing pulse. The pupils may also become very dilated, interfering with vision. Victims become excitable, paranoid, and delirious, losing their sense of reality. Eventually there may be fever, convulsions, respiratory paralysis, coma, and death; or, on recovery, amnesia and depression. There may be a rash, especially on the upper body.

Treatment: Emetics and gastric lavage are indicated if berries have very recently been swallowed. Other treatments may include physostigmine, stimulants, valium, and even coffee. Atropine and other belladonna alkaloids are medically important; they are used as sedatives and antispasmodics. Belladonna extracts were once used in couch medicines.

Famous Cases: Roman Emperor Augustus (27 BC - AD 19)

                            Dr. Crippen (1862-1910)

All information taken from: Poison, An Illustrated History

Autonomic Nervous System

Ok, so this little pain is going to be your new bestie.  The Autonomic Nervous System (ANS) is a very important regulator for homeostasis. The ANS has two branches: Sympathetic (fight or flight) and parasympathetic (rest & digest). MOST(not kidney) organs have dual innervation.

- These postganglionic neurons release norepinephrine (NE), epinephrine (Epi) and dopamine (DA) and MOST of these sympathetic receptors are adrenergic (these receptors will get their own post because they are that important)

- These bad boys are mostly responsible for the release of acetylcholine (ACh); these receptors are cholinergic (muscarinic)

COPD: Tips for step 2 CK and rounds

Hello! I have a pulmonary rotation going on and I thought I’d shed light on management of COPD :D

During rotations, you may be asked what you want to do for the patient. I have written “Plan” for what you might want to answer to impress your attending. I’ve included a few common brand names too :)

Inhalers: Remember inhalers only improve symptoms and have no mortality benefit and do not affect the progression of the disease.

For all patients with COPD: A short-acting bronchodilator (eg, beta-agonist, anticholinergic agent) is prescribed for use as-needed for relief of intermittent increases in dyspnea.
Albuterol PRN

COPDers in whom intermittent short-acting bronchodilators are insufficient to control symptoms or two or more exacerbations in the previous year: Add a regularly scheduled long-acting inhaled bronchodilator. The long-acting inhaled anticholinergic (muscarinic) agent (LAMA) is preferred to the twice daily long-acting beta agonists (LABAs).
Albuterol PRN
Tiotropium OD (Spiriva)

Important for step 2 CK: Inhaled anti-cholinergics are the most effective in COPD.
(Contrary to asthma, where you start Inhaled steroids if symptoms aren’t controlled by short acting bronchodilator like albuterol alone.)
Mnemonic: antiCholinergics are the Coolest in COPD.

For patients who continue to have respiratory symptoms or exercise limitations when using long-acting inhaled bronchodilator monotherapy, add a second long-acting bronchodilator from another class (LAMA or LABA), rather than adding an inhaled glucocorticoid. For patients who continue to have symptoms or have repeated exacerbations despite an optimal long-acting inhaled bronchodilator regimen, add an inhaled glucocorticoid (ICS). An inhaled glucocorticoid may be warranted earlier (ie, at the same time that the long-acting inhaled bronchodilator is initiated) if there are signs of inflammation or an asthmatic component to the COPD.
Personally, I have seen them prescribed together in clinical practice rather than one after the other.
Albuterol PRN
Tiotropium OD
Fluticasone / Salmeterol BD (Adavir)
Or Budesonide / Formoterol BD (Symbicort)

Stuff that has a  mortality benefit:
Oxygen therapy
Smoking cessation
Vaccination (Influenza, pneumococcal)

Clinical pearl: Always ask your COPD patient when was their last flu shot. If your attending asks, you’ll know it like a boss B)

When do you start O2? Start O2 when pO2 < 55, sat < 88%
(Silly question that I asked and answered myself: Why don’t we start O2 right away if it’s so awesomee? Because carrying an O2 cylinder around isn’t always feasible lol.)

Other things to shine on rounds:
Know that COPD is a systemic disease, not just a lung disease - Depression, osteoporosis, weight loss, etc are also a part of the disease.
Read about BODE index.
Know about the anti-inflammatory effects of macrolides in COPD exacerbations.

That’s all!
We rise by lifting others :)

anonymous asked:

Do you have any suggestions to passing the exit RN Hesi?

First, be assured the HESI is a lot harder than the NCLEX!!!!  There are numerous free tests online to practice (google HESI exit).  Quizlet has multiple flashcards available for the HESI.  You can also access study guides on  Also access the HESI website.

HESI Hints & NCLEX Gems

• Answering NCLEX Questions
o Maslow’s Hierarchy of Needs
• Physiologic
• Safety
• Love and Belonging
• Esteem
• Self-actualization
o Nursing Process
• Assessment
• Diagnosis (Analysis)
• Planning
• Implementation (treatment)
• Evaluation
o ABCs
• Airway
• Breathing
• Circulation

• Normal Values
o Hgb
• Males 14-18
• Females 12-16
o Hct
• Males 42-52
• Females 37-47
o RBCs
• Males 4.7-6.1 million
• Females 4.2-5.4 million
o WBCs
• 4.5-11k
o Platelets
• 150-400k
o PT (Coumadin/Warfarin)
• 11-12.5 sec (INR and PT TR = 1.5-2 times normal)
o APTT (Heparin)
• 60-70 sec (APTT and PTT TR = 1.5-2.5 times normal)
o BUN 10-20
o Creatinine 0.5-1.2
o Glucose 70-110
o Cholesterol < 200
o Bilirubin Newborn 1-12
o Phenylalanine Newborn < 2, Adult < 6
o Na+ 136-145
o K+ 3.5-5
• HypoK+ … Prominent U waves, Depressed ST segment, Flat T waves
• HyperK+ … Tall T-Waves, Prolonged PR interval, wide QRS
o Ca++ 9-10.5
• Hypocalcemia … muscle spasms, convulsions, cramps/tetany, + Trousseau’s, + Chvostek’s, prolonged ST interval, prolonged QT segment
o Mg+ 1.5-2.5
o Cl- 96-106
o Phos 3-4.5
o Albumin 3.5-5
o Spec Gravity 1.005-1.030
o Glycosylated Hemoglobin (Hgb A1c): 4-6% ideal, < 7.5% = OK (120 days)
o Dilantin TR = 10-20
o Lithium TR = 0.5-1.5
o Arterial Blood Gases … Used for Acidosis vs. Alkalosis
• PH 7.35-7.45
• CO2 35-45 (Respiratory driver) … High = Acidosis
• HCO3 21-28 (Metabolic driver) … High = Alkalosis
• O2 80-100
• O2 Sat 95-100%

• Antidotes
o Digoxin … Digiband
o Coumadin … Vitamin K (Keep PT and INR @ 1-1.5 X normal)
o Benzodiazapines … Flumzaemil (Tomazicon)
o Magnesium Sulfate … Calcium Gluconate?
o Heparin … Protamine Sulfate (Keep APTT and PTT @ 1.5-2.5 X normal)
o Tylenol … Mucomist (17 doses + loading dose)
o Opiates (narcotic analgesics, heroin, morphine) … Narcan (Naloxone)
o Cholinergic Meds (Myesthenic Bradycardia) … Atropine
o Methotrexate … Leucovorin

• Delegation
o RN Only
• Blood Products (2 RNs must check)
• Clotting Factors
• Sterile dressing changes and procedures
• Assessments that require clinical judgment
• Ultimately responsible for all delegated duties
o Unlicensed Assistive Personnel
• Non-sterile procedures

• Precautions & Room Assignments
o Universal (Standard) Precautions … HIV initiated
• Wash hands
• Wear Gloves
• Gowns for splashes
• Masks and Eye Protection for splashes and droplets
• Don’t recap needles
• Mouthpiece or Ambu-bag for resuscitation
• Refrain from giving care if you have skin lesion
o Droplet (Respiratory) Precautions (Wear Mask)
• Sepsis, Scarlet Fever, Strep, Fifth Disease (Parvo B19), Pertussis, Pneumonia, Influenza, Diptheria, Epiglottitis, Rubella, Rubeola, Meningitis, Mycoplasma, Adenovirus, Rhinovirus
• RSV (needs contact precautions too)
• TB … Respiratory Isolation
o Contact Precautions = Universal + Goggles, Mask and Gown
o No infection patients with immunosuppressed patients

• Weird Miscellaneous Stuff
o Rifampin (for TB) … Rust/orange/red urine and body fluids
o Pyridium (for bladder infection) … Orange/red/pink urine
o Glasgow Coma Scale … < 8 = coma
o Myesthenia Gravis
• Myesthenic Crisis = Weakness with change in vitals (give more meds)
• Cholinergic Crisis = Weakness with no change in vitals (reduce meds)
o Diabetic Coma vs. Insulin Shock … Give glucose first – If no help, give insulin
o Fruity Breath = Diabetic Ketoacidosis
o Acid-Base Balance
• If it comes out of your ass, it’s Acidosis.
• Vomiting = Alkalosis
o Skin Tastes Salty = Cystic Fibrosis
o Lipitor (statins) in PMs only – No grapefruit juice
o Stroke … Tongue points toward side of lesion (paralysis), Uvula deviates away from the side of lesion (paralysis)
o Hold Digoxin if HR < 60
o Stay in bed for 3 hours after first ACE Inhibitor dose
o Avoid Grapefruit juice with Ca++ Channel Blockers
o Anthrax = Multi-vector biohazard
o Pulmonary air embolism prevention = Trendelenburg (HOB down) + on left side (to trap air in right side of heart)
o Head Trauma and Seizures … Maintain airway = primary concern
o Peptic Ulcers … Feed a Duodenal Ulcer (pain relieved by food) … Starve a gastric ulcer
o Acute Pancreatitis … Fetal position, Bluish discoloration of flanks (Turner’s Sign), Bluish discoloration of pericumbelical region (Cullen’s Sign), Board like abdomen with guarding … Self digestion of pancreas by trypsin.
o Hold tube feeding if residual > 100mL
o In case of Fire … RACE and PASS
o Check Restraints every 30 minutes … 2 fingers room underneath
o Gullain-Barre Syndrome … Weakness progresses from legs upward – Resp arrest
o Trough draw = ~30 min before scheduled administration … Peak Draw = 30-60 min after drug administration.

• Mental Health & Psychiatry
o Most suicides occur after beginning of improvement with increase in energy levels
o MAOIs … Hypertensive Crisis with Tyramine foods
• Nardil, Marplan, Parnate
• Need 2 wk gap from SSRIs and TCAs to admin MAOIs
o Lithium Therapeutic Range = 0.5-1.5
o Phenothiazines (typical antipsychotics) – EPS, Photosensitivity
o Atypical Antipsychotics – work on positive and negative symptoms, less EPS
o Benzos (Ativan, Lorazepam, etc) good for Alcohol withdrawal and Status Epilepticus
o Antabuse for Alcohol deterrence – Makes you sick with OH intake
o Alcohol Withdrawal = Delerium Tremens – Tachycardia, tachypnea, anxiety, nausea, shakes, hallucinations, paranoia … (DTs start 12-36 hrs after last drink)
o Opiate (Heroin, Morphine, etc.) Withdrawal = Watery eyes, runny nose, dilated pupils, NVD, cramps
o Stimulants Withdrawal = Depression, fatigue, anxiety, disturbed sleep

• Medical-Surgical
o Hypoventilation = Acidosis (too much CO2)
o Hyperventilation = Alkalosis (low CO2)
o No BP or IV on side of Mastectomy
o Opiate OD = Pinpoint Pupils
o Lesions of Midbrain = Decerebrate Posturing (Extended elbows, head arched back)
o Lesions of Cortex = Decorticate Posturing (Flexion of elbows, wrists, fingers, straight legs, mummy position)
o Urine Output of 30 mL/hr = minimal competency of heart and kidney function
o Kidney Stone = Cholelithiasis
• Flank pain = stone in kidney or upper ureter
• Abdominal/scrotal pain = stone in mid/lower ureter or bladder
o Renal Failure … Restrict protein intake
• Fluid and electrolyte problems … Watch for HyperK+ (dizzy, wk, nausea, cramps, arhythmias)
• Pre-renal Problem = Interference with renal perfusion
• Intra-renal Problem= Damage to renal parenchyma
• Post-renal Problem = Obstruction in UT anywhere from tubules to urethral meatus.
• Usually 3 phases (Oligouric, Diuretic, Recovery)
• Monitor Body Wt and I&Os
o Steroid Effects = Moon face, hyperglycemia, acne, hirsutism, buffalo hump, mood swings, weight gain – Spindle shape, osteoporosis, adrenal suppression (delayed growth in kids) … (Cushing’s Syndrome symptoms)
o Addison’s’ Crisis = medical emergency (vascular collapse, hypoglycemia, tachycardia … Admin IV glucose + corticosteroids) … No PO corticosteroids on empty stomach
o Potassium sparing diuretic = Aldactone (Spironolactone) … Watch for hyperK+ with this and ACE Inhibitors.
o Cardiac Enzymes … Troponin (1 hr), CKMB (2-4 hr), Myoglobin (1-4 hr), LDH1 (12-24 hr)
o MI Tx … Nitro – Yes … NO Digoxin, Betablockers, Atropine
o Fibrinolytics = Streptokinase, Tenecteplase (TNKase)
o CABG = Coronary Artery Bypass Graft
o PTCA = Percutaneous Transluminal Coronary Angioplasty
o Sex after MI okay when able to climb 2 slights of stairs without exertion (Take nitro prophylactically before sex)
o BPH Tx = TURP (Transurethral Resection of Prostate) … some blood for 4 days, and burning for 7 days post-TURP.
o Only isotonic sterile saline for Bladder Irrigation
o Post Thyroidectomy – Keep tracheostomy set by the bed with O2, suction and Calcium gluconate
o Pericarditis … Pericardial Friction Rub, Pain relieved by leaning forward
o Post Strep URI Diseases and Conditions:
• Acute Glomerulonephritis
• Rheumatic Fever … Valve Disease
• Scarlet Fever
o If a chest-tube becomes disconnected, do not clamp … Put end in sterile water
o Chest Tube drainage system should show bubbling and water level fluctuations (tidaling with breathing)
o TB … Treatment with multidrug regimen for 9 months … Rifampin reduces effectiveness of OCs and turns pee orange … Isoniazide (INH) increases Dilantin blood levels
o Use bronchodilators before steroids for asthma … Exhale completely, Inhale deeply, Hold breath for 10 seconds
o Ventilators … Make sure alarms are on … Check every 4 hours minimum
o Suctioning … Pre and Post oxygenate with 100% O2 … No more than 3 passes … No longer than 15 seconds … Suction on withdrawal with rotation
• Emphysema = Pink Puffer
• Chronic Bronchitis = Blue Bloater (Cyanosis, Rt sided heart failure = bloating/edema)
o O2 Administration
• Never more than 6L/min by cannula
• Must humidify with more than 4L/hr
• No more than 2L/min with COPD … (CO2 Narcosis)
• In ascending order of delivery potency: Nasal Cannula, Simple Face Mask, Nonrebreather Mask, Partial Rebreather Mask, Venturi Mask
• Restlessness and Irritability = Early signs of cerebral hypoxia
IVs and Blood Product Administration
o 18-19 gauge needle for blood with filter in tubing
o Run blood with NS only and within 30 minutes of hanging
o Vitals and Breath Sounds … before, during and after infusion (15 min after start, then 30 min later, then hourly up to 1 hr after)
o Check Blood: Exp Date, clots, color, air bubbles, leaks
o 2 RNs must check order, pt, blood product … Ask Pt about previous transfusion Hx
o Stay with Pt for first 15 minutes … If transfusion rxn … Stop and KVO with NS
o Pre-medicate with Benadryl prn for previous urticaria rxns
o Isotonic Solutions
• D5W
• NS (0.9% NaCl)
• Ringers Lactate
• NS only with blood products and Dilantin
Diabetes and Insulin
o When in doubt – Treat for Hypoglycemia first
o First IV for DKA = NS, then infuse regular insulin IV as Rx’d
o Hypoglycemia … confusion, HA, irritable, nausea, sweating, tremors, hunger, slurring
o Hyperglycemia … weakness, syncope, polydipsia, polyuria, blurred vision, fruity breath
o Insulin may be kept at room T for 28 days
o Draw Regular (Clear) insulin into syringe first when mixing insulins
o Rotate Injection Sites (Rotate in 1 region, then move to new region)
o Rapid Acting Insulins … Lispro (Humalog) and Aspart (Novolog) … O: 5-15 min, P: .75-1.5 hrs
o Short Acting Insulin … Regular (human) … O: 30-60 min, P: 2-3 hrs (IV Okay)
o Intermediate Acting Insulin … Isophane Insulin (NPH) … O: 1-2 hrs, P: 6-12 hrs
o Long Acting Insulin … Insulin Glargine (Lantus) … O: 1.1 hr, P: 14-20 hrs (Don’t Mix)
o Oral Hypoglycemics decrease glucose levels by stimulating insulin production by beta cells of pancreas, increasing insulin sensitivity and decreasing hepatic glucose production
• Glyburide, Metformin (Glucophage), Avandia, Actos
• Acarbose blunts sugar levels after meals
o Leukemia … Anemia (reduced RBC production), Immunosuppression (neutropenia and immature WBCs), Hemorrhage and bleeding tendencies (thrombocytopenia)
• Acute Lymphocytic = most common type, kids, best prognosis
o Testicular Cancer … Painless lump or swelling testicle … STE in shower > 14 yrs … 15-35 = Age
o Prostate Cancer … > 40 = Age
• PSA elevation
• Mets to spine, hips, legs
• Elevated PAP (prostate acid phosphatase)
• TRUS = Transurethral US
• Post Op … Monitor of hemorrhage and cardiovascular complication
o Cervical and Uterine Cancer
• Laser, cryotherapy, radiation, conization, hysterectomy, exenteration … Chemotherapy = No help
• PAP smears should start within 3 years of intercourse or by age 21
o Ovarian Cancer = leading cause of death from gynecological cancer
o Breast Cancer = Leading cause of cancer in women
• Upper outer quadrant, left > right
• Monthly SBE
• Mammography … Baseline @ 35, Annually after age 50
• Mets to lymph nodes, then lungs, liver, brain, spine
• Mastectomy … Radical Mastectomy = Lymph nodes too (but no mm resected)
• Avoid BP measurements, injections and venipuncture on surgical side
o Anti-emetics given with Chemotherapy Agents (Cytoxan, Methotrexate, Interferon, etc.)
• Phenergan (Promethazine HCl)
• Compazine (Prochlorperazine)
• Reglan (Metocolpramide)
• Benadryl (Diphenhydramine)
• Zofran (Ondansetron HCl)
• Kytril (Granisetron)
Sexually Transmitted Diseases
o Syphilis (Treponema pallidum) … Chancre + red painless lesion (Primary Stage, 90 days) … Secondary Stage (up to 6 mo) = Rash on palms and soles + Flu-like symptoms … Tertiary Stage = Neurologic and Cardiac destruction (10-30 yrs) … Treated with Penicillin G IM.
o Gonorrhea (Neisseria Gonorrhea) … Yellow green urethral discharge (The Clap)
o Chlamydia (Chlamydia Trachomatis) … Mild vaginal discharge or urethritis … Doxycyclin, Tetracycline
o Trichomoniasis (Trichomonas Vaginalis) … Frothy foul-smelling vaginal discharge … Flagyl
o Candidiasis (Candida Albicans) … Yellow, cheesy discharge with itching … Miconazole, Nystatin, Clomitrazole (Gyne-Lotrimin)
o Herpes Simplex 2 … Acyclovir
o HPV (Human Pappilovirus) … Acid, Laser, Cryotherapy
o HIV … Cocktails

• Perioperative Care
o Breathing Es taught in advance (before or early in pre-op)
o Remove nail polish (need to see cap refill)
o Pre Op … Meds as ordered, NPO X 8 hrs, Incentive Spirometry & Breathing Es taught in advance, Void, No NSAIDS X 48 hrs
o Increased corticosteroids for surgery (stress) … May need to increase insulin too
o Post Op restlessness may = hemorrhage, hypoxia
o Wound dehiscence or extravisation … Wet sterile NS dressing + Call Dr.
o Call Dr. post op if … < 30 mL/hr urine, Sys BP < 90, T > 100 or < 96
o Post Op Monitoring VS and BS … Every 15 minutes the first hour, Every 30 min next 2 hours, Every hour the next 4 hours, then Every 4 hours prn
o 1-4 hrs Post Op = Immediate Stage … 2-24 hrs Post Op = Intermediate Stage … 1-4 days Post Op = Extended Stage
o Post Op Positioning
• THR … No Adduction past midline, No hip flexion past 90 degrees
• Supratentorial Sx … HOB 30-45 degrees (Semi-Fowler)
• Infrantentorial Sx … Flat
• Phlebitis … Supine, elevate involved leg
• Harris Tube … Rt/back/Lt – to advance tube in GI
• Miller Abbott Tube … Right side for GI advancement into small intestine
• Thoracocentesis … Unaffected side, HOB 30-45 degrees
• Enema … Left Sims (flow into sigmoid)
• Liver Biopsy … Right side with pillow/towel against puncture site
• Cataract Sx … Opp side – Semi-Fowler
• Cardiac Catheterization … Flat (HOB no more than 30 degrees), Leg straight 4-6 hrs, bed rest 6-12 hrs
• Burn Autograph … Elevated and Immob 3-7 days
• Amputation … Supine, elevate stump for 48 hrs
• Large Brain Tumor Resection … On non-operative side
o Incentive Spirometry … Inhale slowly and completely to keep flow at 600-900, Hold breath 5 seconds, 10 times per hr
o Post Op Breathing Exercises … Every 2 hours
• Sit up straight
• Breath in deeply thru nose and out slowly thru pursed lips
• Hold last breath 3 seconds
• Then cough 3 times (unless abd wound – reinforce/splint if cough)
o Watch for Stridor after any neck/throat Sx … Keep Trach kit at bed side
o Staples and sutures removed in 7-14 days – Keep dry until then
o No lifting over 10 lbs for 6 weeks (in general)
o If chest tube comes disconnected, put free end in container of sterile water
o Removing Chest Tube … Valsalvas, or Deep breath and hold
o If chest tube drain stops fluctuating, the lung has re-inflated (or there is a problem)
o Keep scissors by bed if pt has S. Blakemore Tube (for esoph varices)… Sudden respiratory distress – Cut inflation tubes and remove
o Tracheostomy patients … Keep Kelly clamp and Obturator (used to insert into trachea then removed leaving cannula) at bed side
o Turn off NG suction for 30 min after PO meds
o NG Tube Removal … Take a deep breath and hold it
o Stomach contents pH = < 4 (gastric juices aspirated)
o NG Tube Insertion … If cough and gag, back off a little, let calm, advance again with pt sipping water from straw
o NG Tube Length … End of nose, to era lobe, to xyphoid (~22-26 inches)
o Decubitus (pressure) Ulcer Staging
• Stage 1 = Erythema only
• Stage 2 = Partial thickness
• Stage 3 = Full thickness to SQ
• Stage 4 = Full thickness + involving mm /bone

• Acute Care
o CVA … Hemorrhagic or Embolic
• A-fib and A-flutter = thrombus formation
• Dysarthria (verbal enunciation/articulation), Apraxia (perform purposeful movements), Dysphasia (speech and verbal comprehension), Aphasia (speaking), Agraphia (writing), Alexia (reading), Dysphagia (swallowing)
• Left Hemisphere Lesion … aphasia, agraphia, slow, cautious, anxious, memory okay
• Right Hemisphere Lesion … can’t recognize faces, loss of depth perception, impulsive behavior, confabulates, poor judgment, constantly smiles, denies illness, loss of tonal hearing
o Head Injuries …
• Even subtle changes in mood, behavior, restlessness, irritability, confusion may indicate increased ICP
• Change in level of responsiveness = Most important indicator of increased ICP
• Watch for CSF leaks from nose or ears – Leakage can lead to meningitis and mask intracranial injury since usual increased ICP symps may be absent.
o Spinal Cord Injuries
• Respiratory status paramount … C3-C5 innervates diaphragm
• 1 wk to know ultimate prognosis
• Spinal Shock = Complete loss of all reflex, motor, sensory and autonomic activity below the lesion = Medical emergency
• Permanent paralysis if spinal cord in compressed for 12-24 hrs
• Hypotension and Bradycardia with any injury above T6
• Bladder Infection = Common cause of death (try to keep urine acidic)
o Burns
• Infection = Primary concern
• HyperK+ due to cell damage and release of intracellular K+
• Give meds before dressing changes – Painful
• Massive volumes of IV fluid given, due to fluid shift to interstitial spaces and resultant shock
• First Degree = Epidermis (superficial partial thickness)
• Second Degree = Epidermis and Dermis (deep partial thickness)
• Third Degree = Epidermis, Dermis, and SQ (full thickness)
• Rule of 9s … Head and neck = 9%, UE = 9% each, LE = 18% each, Front trunk = 18%, Back Trunk = 18%
• Singed nasal hair and circumoral soot/burns = Smoke inhalation burns
o Fractures
• Report abnormal assessment findings promptly … Compartment Syndrome may occur = Permanent damage to nerves and vessels
• 5 P’s of neurovascular status (important with fractures)
• Pain, Pallor, Pulse, Paresthesia, Paralysis
• Provide age-appropriate toys for kids in traction

• Special Tests and Pathognomonic Signs
o Tensilon Test … Myesthenia Gravis (+ in Myesthenic crisis, - in Cholinergic crisis)
o ELISA and Western Blot … HIV
o Sweat Test … Cystic Fibrosis
o Cheilosis = Sores on sides of mouth … Riboflavin deficiency (B2)
o Trousseau’s Sign (Carpal spasm induced by BP cuff) … Hypocalcemia (hypoparathyroidism)
o Chvostek’s Sign (Facial spasm after facial nerve tap) … Hypocalcemia (hypoparathyroidism)
o Bloody Diarrhea = Ulcerative Colitis
o Olive-Shaped Mass (epigastric) and Projectile Vomiting = Pyloric Stenosis
o Current Jelly Stool (blood and mucus) and Sausage-Shaped Mass in RUQ = Intussiception
o Mantoux Test for TB is + if 10 mm induration 48 hrs post admin (previous BCG vaccine recipients will test +)
o Butterfly Rash = SLE … Avoid direct sunlight
o 5 Ps of NV functioning … Pain, paresthesia, pulse, pallor, paralysis
o Cullen’s Sign (periumbelical discoloration) and Turner’s Sign (blue flank) = Acute Pancreatitis
o Murphy’s Sign (Rt. costal margin pain on palp with inspiration) = GB or Liver disease
o HA more severe on wakening = Brain Tumor (remove benign and malignant)
o Vomiting not associated with nausea = Brain Tumor
o Elevated ICP = Increased BP, widened pulse pressure, increased Temp
o Pill-Rolling Tremor = Parkinson’s (Tx with Levodopa, Cardidopa) – Fall precautions, rigid, stooped, shuffling
o IG Bands on Electrophoresis = MS … Weakness starts in upper extremities – bowel/bladder affected in 90% … Demyelination - Tx with ACTH, corticosteroids, Cytoxan and other immunosuppressants
o Reed-Sternberg Cells = Hodgkin’s
o Koplik Spots = Rubeola (Measles)
o Erythema Marginatum = Rash of Rheumatic Fever
o Gower’s Sign = Muscular Dystrophy … Like Minor’s sign (walks up legs with hands)

• Pediatrics
o Bench Marks
• Birth wt doubles at 6 months and triples at 12 months
• Birth length increases by 50% at 12 months
• Post fontanel closes by 8 wks
• Ant fontanel closes by 12-18 months
• Moro reflex disappears at 4 months
• Steady head control achieved at 4 months
• Turns over at 5-6 months
• Hand to hand transfers at 7 months
• Sits unsupported at 8 months
• Crawls at 10 months
• Walks at 10-12 months
• Cooing at 2 months
• Monosyllabic Babbling at 3-6 months, Links syllables 6-9 mo
• Mama, Dada + a few words at 9-12 months
• Throws a ball overhand at 18 months
• Daytime toilet training at 18 mo - 2 years
• 2-3 word sentences at 2 years
• 50% of adult Ht at 2 years
• Birth Length doubles at 4 years
• Uses scissors at 4 years
• Ties shoes at 5 years
• Girls’ growth spurt as early at 10 years … Boys catch up ~ Age 14
• Girls finish growing at ~15 … Boys ~ 17
o Autosomal Recessive Diseases
• CF, PKU, Sickle Cell Anemia, Tay-Sachs, Albinism,
• 25% chance if: AS (trait only) X AS (trait only)
• 50% chance if: AS (trait only) X SS (disease)
o Autosomal Dominant Diseases
• Huntington’s, Marfans, Polydactyl, Achondroplasia, Polycystic Kidney Disease
• 50% if one parent has the disease/trait (trait = disease in autosomal dominant)
o X-Linked Recessive Diseases
• Muscular Dystrophy, Hemophilia A
• Females are carriers (never have the disease)
• Males have the disease (but can’t pass it on)
• 50% chance daughters will be carriers (can’t have disease)
• 50% chance sons will have the disease (not a carrier = can’t pass it on)
• This translates to an overall 25% chance that each pregnancy will result in a child that has the disease
o Scoliosis … Milwaukee Brace – 23 hrs/day, Log rolling after Sx
o Down Syndrome = Trisomy 21 … Simian creases on palms, hypotonia, protruding tongue, upward outward slant of eyes
o Cerebral Palsy … Scissoring = legs extended, crossed, feet plantar-flexed
o PKU … leads to MR … Guthrie Test …Aspartame (NutraSweet) has phenylalanine in it and should not be given to PKU patient
o Hypothyroidism … Leads to MR
o Prevent Neural tube disorders with Folic Acid during PG
o Myelomeningocele … Cover with moist sterile water dressing and keep pressure off
o Hydrocephalus … Signs of increased ICP are opposite of shock …
• Shock = Increased pulse and decreased BP
• IICP = Decreased pulse and increased BP … (+ Altered LOC = Most sensitive sign)
• Infants … IICP = Bulging fontanels, high pitched cry, increased hd circum, sunset eyes, wide suture lines, lethargy … Treat with peritoneal shunt – don’t pump shunt. Older kids IIPC = Widened pulse pressure
• IICP caused by suctioning, coughing, straining, and turning – Try to avoid
o Muscular Dystrophy … X-linked Recessive, waddling gait, hyper lordosis, Gower’s Sign = difficulty rising walks up legs (like Minor’s sign), fat pseudohypertrophy of calves.
o Seizures … Nothing in mouth, turn hd to side, maintain airway, don’t restrain, keep safe … Treat with Phenobarbitol (Luminol), Phenytoin (Dilantin: TR = 10-20 … Gingival Hyperplasia), Fosphenytoin (Cerebyx), Valproic Acid (Depakene), Carbamazepine (Tegritol)
o Meningitis (Bacterial) … Lumbar puncture shows Increased WBC, protein, IICP and decreased glucose
• May lead to SIADH (Too much ADH) … Water retention, fluid overload, dilutional hyponatremia
o CF Kids taste salty and need enzymes sprinkled on their food
o Children with Rubella = threat to unborn siblings (may require temporary isolation from Mom during PG)
o Pain in young children measured with Faces pain scale
o No MMR Immunization for kids with Hx of allergic rxn to eggs or neomycin
o Immunization Side Effects … T < 102, redness and soreness at injection site for 3 days … give Tylenol and bike pedal legs (passively) for child.
o Call Physician if seizures, high fever, or high-pitched cry after immunization
o All cases of poisoning … Call Poison Control Center … No Ipecac!
o Epiglottitis = H. influenza B … Child sits upright with chin out and tongue protruding (maybe Tripod position) … Prepare for intubation or trach … DO NOT put anything into kid’s mouth
o Isolate RSV patient with Contact Precautions … Private room is best … Use Mist Tent to provide O2 and Ribavirin – Flood tent with O2 first and wipe down inside of tent periodically so you can see patient
o Acute Glomerulonephritis … After B strep – Antigen-Antibody complexes clog up glomeruli and reduce GFR = Dark urine, proteinuria
o Wilm’s Tumor = Large kidney tumor … Don’t palpate
o TEF = Tracheoesophageal Atresia … 3 C’s of TEF = Coughing, Choking, Cyanosis
o Cleft Lip and Palate … Post-Op – Place on side, maintain Logan Bow, elbow restraints
o Congenital Megacolon = Hirschsprung’s Disease … Lack of peristalsis due to absence of ganglionic cells in colon … Suspect if no meconium w/in 24 hrs or ribbon-like foul smelling stools
o Iron Deficiency Anemia … Give Iron on empty stomach with citrus juice (vitamin C enhances absorption), Use straw or dropper to avoid staining teeth, Tarry stools, limit milk intake < 32 oz/day
o Sickle Cell Disease …Hydration most important …SC Crisis = fever, abd pain, painful edematous hands and feet (hand-foot syndrome), arthralgia …Tx + rest, hydration … Avoid high altitude and strenuous activities
o Tonsillitis … usually Strep … Get PT and PTT Pre-Op (ask about Hx of bleeding) … Suspect Bleeding Post-Op if frequent swallowing, vomiting blood, or clearing throat … No red liquids, no straws, ice collar, soft foods … Highest risk of hemorrhage = first 24 hrs and 5-10 days post-op (with sloughing of scabs)
o Primary meds for ER for respiratory distress = Sus-phrine (Epinephrine HCl) and Theophylline (Theo-dur) … Bronchodilators
o Must know normal respiratory rates for kids … Respiratory disorders = Primary reason for most medical/ER visits for kids …
• Newborn … 30-60
• 1-11 mo … 25-35
• 1-3 years … 20-30
• 3-5 years … 20-25
• 6-10 years … 18-22
• 11-16 years …16-20
Cardiovascular Disorders
o Acyanotic = VSD, ASD, PDA, Coarc of Aorta, Aortic Stenosis
• Antiprostaglandins cause closure of PDA (aorta - pulmonary artery)
o Cyanotic = Tetralogy of Fallot, Truncus Arteriosis (one main vessel gets mixed blood), TVG (Transposition of Great Vessels) … Polycythemia common in Cyanotic disorders
• 3 T’s of Cyanotic Heart Disease (Tetralogy, Truncus, Transposition)
o Tetralogy of Fallot … Unoxygenated blood pumped into aorta
• Pulmonary Stenosis
• Overiding Aorta
• Right Ventricular Hypertrophy
• TET Spells …Hypoxic episodes that are relieved by squatting or knee chest position
o CHF can result … Use Digoxin … TR = 0.8-2.0 for kids
o Ductus Venosus = Umbelical Vein to Inferior Vena Cava
o Ductus Arteriosus = Aorta to Pulmonary Artery
o Rheumatic Fever … Acquired Heart Disease … Affects aortic and mitral valves
• Preceded by beta hemolytic strep infection
• Erythema Marginatum = Rash
• Elevated ASO titer and ESR
• Chest pain, shortness of breath (Carditis), migratory large joint pain, tachycardia (even during sleep)
• Treat with Penicillin G = Prophylaxis for recurrence of RF

• Maternity
o Day 1 of cycle = First day of menses (bleeding) … Ovulation on Day 14 … 28 days total … Sperm 3-5 days, Eggs 24 hrs … Fertilization in Fallopian Tube
o Chadwick’s Sign = Bluing of Vagina (early as 4 weeks)
o Hegar’s Sign = Softening of isthmus of cervix (8 weeks)
o Goodell’s Sign = Softening of Cervix (8 weeks)
o Pregnancy Total wt gain = 25-30 lbs (11-14 kg)
o Increase calorie intake by 300 calories/day during PG … Increase protein 30 g/day … Increase iron, Ca++, Folic Acid, A & C
o Dangerous Infections with PG … TORCH = Toxoplasmosis, other, Rubella, Cytomegalovirus, HPV
o Braxton Hicks common throughout PG
o Amniotic fluid = 800-1200 mL (< 300 mL = Oligohydramnios = fetal kidney problems)
o Polyhydramnios and Macrosomia (large fetus) with Diabetes
o Umbelical cord: 2 arteries, 1 vein … Vein carries oxygenated blood to fetus (opposite of normal)
o FHR = 120-160
o Folic Acid Deficiency = Neural tube defects
o Pre-term = 20-37 weeks
o Term = 38-42 weeks
o Post-term = 42 weeks+
o TPAL = Term births, Pre-term births, Abortions, Living children
o Gravida = # of Pregnancies regardless of outcome
o Para = # of Deliveries (not kids) after 20 wks gestation
o Nagale’s Rule … Add 7 days to first day of last period, subtract 3 months, add 12 months = EDC
o Hgb and Hct a bit lower during PG due to hyperhydration
o Side-lying is best position for uteroplacental perfusion (either side tho left is traditional )
o 2:1 Lecithin:Sphingomyelin Ratio = Fetal lungs mature
o AFP in amniotic fluid = possible neural tube defect
o Need a full bladder for Amniocentesis early in PG (but not in later PG)
o Lightening = Fetus drops into true pelvis
o Nesting Instinct = Burst of Energy just before labor
o True Labor = Regular contractions that intensify with ambulation, LBP that radiates to abdomen, progressive dilation and effacement
o Station = Negative above ischial spines, Positive below
o Leopold Maneuver tries to reposition fetus for delivery
o Laboring Maternal Vitals … Pulse < 100 (usually a little higher than normal with PG - BP is unchanged in PG). T < 100.4
o NON-Stress Test … Reactive = Healthy (FHR goes up with movements)
o Contraction Stress Test (Ocytocin Challenge Test)… Unhealthy = Late decels noted (positive result) indicative of UPI … “Negative” result = No late decels noted (good result)
o Watch for hyporeflexia with Mag Sulfate admin … Diaphragmatic Inhibition
• Keep Calcium gluconate by the bed (antidote)
o Firsts
• Fetal HB … 8-12 weeks by Doppler, 15-20 weeks by fetoscope
• Fetal movement = Quickening, 14-20 weeks
• Showing = 14 weeks
• Braxton Hicks – 4 months and onward
o Early Decels = Head compression = OK
o Variable Decels = Cord compression = Not Good
o Late Decels = Utero-placental insufficiency = BAD!
o If Variable or Late Decels … Change maternal position, Stop Pitocin, Administer O2, Notify Physician
o DIC … Tx is with Heparin (safe in PG) … Fetal Demise, Abruptio Placenta, Infection
o Fundal Heights
• 12-14 wks … At level of symphysis
• 20 weeks … 20 cm = Level of umbilicus
• Rises ~ 1 cm per week
o Stages of Labor
• Stage 1 = Beginning of Regular contraction to full dilation and effacement
• Stage 2 = 10 cm dilation to delivery
• Stage 3 = Delivery of Placenta
• Stage 4 = 1-4 Hrs following delivery
o Placenta Separation … Lengthening of cord outside vagina, gush of blood, full feeling in vagina … Give oxytocin after placenta is out – Not before.
o Schultz Presentation = Shiny side out (fetal side of placenta)
o Postpartum VS Schedule
• Every 15 min X 1 hr
• Every 30 min X next 2 hours
• Every Hour X next 2-6 hours
• Then every 4 hours
o Normal BM for mom within 3 days = Normal
o Lochia … no more than 4-8 pads/day and no clots > 1 cm … Fleshy smell is normal, Foul smell = infection
o Massage boggy uterus to encourage involution … empty bladder ASAP – may need to catheterize … Full bladder can lead to uterine atony and hemorrhage
o Tears …1st Degree = Dermis, 2nd Degree = mm/fascia, 3rd Degree = anal sphincter, 4th Degree = rectum
o APGAR = HR, R, mm tone, Reflex irritability, Color … 1 and 5 minutes …7-10 = Good, 4-6 = moderate resuscitative efforts, 1-3 = mostly dead
o Eye care = E-mycin + Silver Nitrate … for gonorrhea
o Pudendal Block = decreases pain in perineum and vagina – No help with contraction pain
o Epidural Block = T10-S5 … Blocks all pain … First sign = warmth or tingling in ball of foot or big toe
o Regional Blocks often result in forceps or vacuum assisted births because they affect the mother’s ability to push effectively
o WBC counts are elevated up to 25,000 for ~10 days post partum
o Rho(D) immune globulin (RhoGAM) is given to Rh- mothers who deliver Rh+ kids… Not given if mom has a +Coombs Test … She already has developed antibodies (too late)
o Caput Succedaneum = edema under scalp, crosses suture lines
o Cephalhematoma = blood under periosteum, does not cross suture lines
o Suction Mouth first – then nostrils
o Moro Reflex = Startle reflex (abduction of all extremities) – up to 4 months
o Rooting Reflex … up to 4 months
o Babinski Reflex … up to18 months
o Palmar Grasp Reflex …Lessens by 4 months
o Ballard Scale used to estimate gestational age
o Heel Stick = lateral surface of heel
o Physiologic Jaundice is normal at 2-3 days … Abnormal if before 24 hours or lasting longer than 7 days … Unconjugated bilirubin is the culprit.
o Vitamin K given to help with formation of clotting factors due to fact that the newborn gut lacks the bacteria necessary for vitamin K synthesis initially … Vastus lateralis mm IM
o Abrutio Placenta = Dark red bleeding with rigid board like abdomen
o Placenta Previa = Painless bright red bleeding
o DIC = Disseminated Intravascular Coagulation … clotting factors used up by intravascular clotting – Hemorrhage and increased bleeding times result … Associated with fetal demise, infection and abruptio placenta.
o Magnesium Sulfate used to reduce preterm labor contractions and prevent seizures in Pre-Eclampsia … Mg replaces Ca++ in the smooth mm cells resulting relaxation … Can lead to hyporeflexia and respiratory depression – Must keep Calcium Gluconate by bed when administering during labor = Antidote … Monitor for:
• Absent DTR’s
• Respirations < 12
• Urinary Output < 30/hr
• Fetal Bradycardia
o Pitocin (Oxytocin) use for Dystocia… If uterine tetany develops, turn off Pitocin, admin O2 by face mask, turn pt on side. Pitocin can cause water intoxication owing to ADH effects.
o Suspect uterine rupture if woman complains of a sharp pain followed by cessation of contractions
o Pre-Eclampsia = Htn + Edema + Proteinuria
o Eclampsia = Htn + Edema + Proteinuria + Seizures and Coma … Suspect if Severe HA + visual disturbances
o No Coumadin during PG (Heparin is OK)
o Hyperemesis Gravidarum = uncontrollable nausea and vomiting … May be related to H. pyolori … Reglan (metaclopromide)
o Insulin demands drop precipitously after delivery
o No oral hypoglycemics during PG – Teratogenic … Insulin only for control of DM
o Babies born without vaginal squeeze more likely to have respiratory difficulty initially
o C-Section can lead to Paralytic Ileus … Early ambulation helps
o Postpartum Infection common in problem pregnancies (anemia, diabetes, traumatic birth)
o Postpartum Hemorrhage = Leading cause of maternal death … Risk factors include:
• Dystocia, prolonged labor, overdistended uterus, abrutio placenta, infection
Tx includes … Fundal massage, count pads, VS, IV fluids, Oxytocin, notify physician
o Jitteriness is a symptom of hypoglycemia and hypocalcemia in the newborn
o Hypoglycemia … tremors, high pitched cry, seizures
o High pitched cry + bulging fontanels = IICP
o Hypothermia can lead to Hypoxia and acidoisis … Keep warm and use bicarbonate prn to treat acidosis in newborn.
o Lay on right side after feeding … Move stomach contents into small intestine
o Jaundice and High bilirubin can cause encephalopathy … < 12 = normal … Phototherapy decomposes bilirubin via oxidation … Protect eyes, turn every 2 hours and watch for dehydration … The dangerous bilirubin is the unconjugated indirect type.

• Nutrition
o K+ … Bananas, dried fruits, citrus, potatoes, legumes, tea, peanut butter
o Vitamin C … Citrus, potatoes, cantaloupe
o Ca++ … Milk, cheese, green leafy veggies, legumes
o Na+ … Salt, processed foods, seafood
o Folic Acid … Green leafy veggies, liver, citrus
o Fe++ … Green leafy veggies, red meat, organ meat, eggs, whole wheat, carrots
• Use Z-track for injections to avoid skin staining
o Mg+ … Whole grains, green leafy veggies, nuts
o Thiamine (B1) … Pork, beef, liver, whole grains
o B12 … Organ meats, green leafy veggies, yeast, milk, cheese, shellfish
• Deficiency = Big red beefy tongue, Anemia
o Vitamin K … Green leafy veggies, milk, meat, soy
o Vitamin A … Liver, orange and dark green fruits and veggies
o Vitamin D … Dairy, fish oil, sunlight
o Vitamin E … Veggie oils, avocados, nuts, seeds
o BMI … 18.5-24.9 = Normal (Higher = Obese)

• Gerontology
o Essentially everyone goes to Hell in a progressively degenerative hand-basket
• Thin skin, bad sleep, mm wasting, memory loss, bladder shrinks, incontinence, delayed gastric emptying, COPD, Hypothyroidism, Diabetes

o Common Ailments:
• Delerium and Dementia
• Cardiac Dysrhythmias
• Cataracts and Glaucoma
• CVA (usually thrombotic, TIAs common)
• Decubitus Ulcers
• Hypothyroidism
• Thyrotoxicosis (Grave’s Disease)
• COPD (usually combination of emphysema and CB)
• UTIs and Pneumonia … Can cause confusion and delerium
o Memory loss starts with recent – progresses to full
o Dementia = Irreversible (Alzheimer’s) … Depression, Sundowning, Loss of family recognition
o Delerium = Secondary to another problem = Reversible (infections common cause)
o Medication Alert! … Due to decreased renal function, drugs metabolized by the kidneys may persist to toxic levels
o When in doubt on NCLEX … Answer should contain something about exercise and nutrition.

• Advanced Clinical Concepts
o Erickson … Psycho-Social Development
• 0-1 yr (Newborn) … Trust vs. Mistrust
• 1-3 yrs (Toddler)… Autonomy vs. Doubt and Shame … Fear intrusive procedures - Security objects good (Blankies, stuffed animals)
• 3-6 yrs (Pre-school) … Initiative vs. Guilt … Fear mutilation – Band-Aids good
• 6-12 yrs (School Age) … Industry vs. Inferiority… Games good, Peers important … Fear loss of control of their bodies
• 12-19 yrs (Adolescent) … Identity vs. Role Confusion … Fear Body Image Distortion
• 20-35 yrs (Early Adulthood) … Intimacy vs. Isolation
• 35-65 yrs (Middle Adulthood) … Generativity vs. Stagnation
• Over 65 (Older Adulthood) … Integrity vs. Despair
o Piaget … Cognitive Development
• Sensorimotor Stage (0-2) … Learns about reality and object permanence
• Preoperational Stage (2-7) … Concrete thinking
• Concrete Operational Stage (7-11) … Abstract thinking
• Formal Operational Stage (11-adult) … Abstract and logical thinking
o Freud … Psycho-Sexual Development
• Oral Stage (Birth -1 year) … Self gratification, Id is in control and running wild
• Anal Stage (1-3) … Control and pleasure wrt retention and pooping – Toilet training in this stage
• Phallic Stage (3-6) … Pleasure with genitals, Oedipus complex, SuperEgo develops
• Latency Stage (6-12) … Sex urges channeled to culturally acceptable level, Growth of Ego
• Genital Stage (12 up) … Gratification and satisfying sexual relations, Ego rules
o Kohlberg … Moral Development
• Moral development is sequential but people do not aromatically go from one stage to the next as they mature
• Level 1 = Pre-conventional … Reward vs. Punishment Orientation
• Level 2 = Conventional Morality … Conforms to rules to please others
• Level 3 = Post- Conventional … Rights, Principles and Conscience (Best for All is a concern)

• Calculations Rules & Formulas
o Round final answer to tenths place
o Round drops to nearest drop
o When calculating mL/hr, round to nearest full mL
o Must include 0 in front of values < 1
o Pediatric doses rounded to nearest 100th. Round down for peds
o Calculating IV Flow Rates
• Total mL X Drop Factor / 60 X #Hrs = Flow Rate in gtts/min
o Calculating Infusion Times
• Total mL X Drop Factor / Flow Rate in gtts/min X 60 = Hrs to Infuse

• Conversions
o 1 t = 5mL
o 1 T = 3 t = 15 mL
o 1 oz = 30 cc = 30 mL = 2 T
o 1 gr = 60 mg
o 1 mg = 1000 ug (or mcg)
o 1 kg = 2.2 lbs
o 1 cup = 8 oz = 240 mL
o 1 pint = 16 oz
o 1 quart = 32 oz
o Degrees F = (1.8 X C) + 32
o Degrees C = (F – 32) / 1.8
• 37 C = 98.6 F
• 38 C = 100.4 F
• 39 C = 102.2 F
• 40 C = 104 F

• Fall Precautions
o Room close to nurses station
o Assessment and orientation to room
o Get help to stand (dangle feet if light headed)
o Bed low with side rails up
o Good lighting and reduce clutter in room
o Keep consistent toileting schedule
o Wear proper non-slip footwear
o At home …
• Paint edges of stairs bright color
• Bell on cats and dogs

• Neutropenic (Immunosuppressed) Precautions
o No plants or flowers in room
o No fresh veggies … Cooked foods only
o Avoid crowds and infectious persons
o Meticulous hand washing and hygiene to prevent infection
o Report fever > 100.5 (immunosuppressed pts may not manifest fever with infection)

• Bleeding Precautions (Anticoagulants, etc.)
o Soft bristled tooth brush
o Electric razor only (no safety razors)
o Handle gently, Limit contact sports
o Rotate injection sites with small bore needles for blood thinners
o Limit needle sticks, Use small bore needles, Maintain pressure for 5 minutes on venipuncture sites
o No straining at stool - Check stools for occult blood (Stool softeners prn)
o No salicylates, NSAIDs, or suppositories
o Avoid blowing or picking nose
o Do not change Vitamin K intake if on Coumadin

Hope this helps….MS. D