Study Guides – Nclexspark

Nursing Study Guides

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Fundamentals

Core nursing concepts, safety, infection control, communication and documentation

•Physiological (survival): airway, breathing, circulation, food, water, shelter

•Safety/Security: environment free from harm

•Love/Belonging: relationships, social connection

•Esteem: self-worth, achievement, recognition

•Self-Actualization: personal growth, fulfillment

⚡ NCLEX priority: ALWAYS address physiological needs first

•Airway → Breathing → Circulation → then all else

•Cannot address higher needs until lower are met

•Temperature: 36.1–37.2°C (97–99°F) oral; rectal is highest, axillary is lowest

•Pulse: 60–100 bpm; count apical for 1 full minute if irregular

•Respiration: 12–20 breaths/min; count for 1 full minute if irregular

•Blood Pressure: less than 120/80 is normal; hypertension is 130/80 or higher; hypotension below 90/60

•SpO2: 95–100% normal; COPD target 88–92%

•Pain: 0–10 numeric scale; reassess 30 min after any intervention

•Standard Precautions: all patients; gloves for blood and body fluids

•Contact: gloves and gown — MRSA, C. diff, RSV, Scabies, VRE

•Droplet: surgical mask within 3 ft — Influenza, Mumps, Meningitis, Pertussis

•Airborne: N95 respirator and negative-pressure room — TB, Measles, Chickenpox

•PPE donning order: gown, mask, goggles, gloves

•PPE doffing order: gloves, goggles, gown, mask (most contaminated removed first)

⚡ C. diff requires soap and water — alcohol-based hand rubs do NOT kill spores

•Right Patient — verify 2 identifiers (name + DOB or MRN) before every medication

•Right Drug — confirm generic and trade name; do not abbreviate

•Right Dose — calculate; double-check high-alert drugs with a second nurse

•Right Route — IV, PO, IM, SubQ, topical, sublingual

•Right Time — scheduled, STAT, or PRN

•Right Reason — understand the clinical indication

•Right Documentation — chart immediately after administering

•Right Response — assess effectiveness; document outcome

•Right Education — teach patient about medication, dose, and side effects

⚡ Three checks: removing from storage, before preparing, before administering

•Never crush: enteric-coated, sustained-release (-XL/-ER/-SR), or sublingual tablets

•Isotonic (0.9% NS, LR, D5W): stays in intravascular space — used for hypovolemia and surgery

•Hypotonic (0.45% NS): shifts fluid INTO cells — used for dehydration and hypernatremia

•Hypertonic (3% NS, D10W): pulls fluid OUT of cells — used for severe hyponatremia and cerebral edema

•IV rate formula: Volume divided by Time in hours = mL/hr

•Drip rate: Volume times Drop factor, divided by Time in minutes = gtt/min

•Infiltration: swelling, coolness, pallor — STOP infusion immediately

•Phlebitis: redness, warmth, pain along vein — remove IV and apply warm compress

•Stage 1: Non-blanchable redness; skin intact

•Stage 2: Partial-thickness skin loss; shallow open ulcer or intact blister

•Stage 3: Full-thickness loss; subcutaneous tissue visible; no bone or tendon

•Stage 4: Full-thickness; bone, tendon, or muscle visible

•Unstageable: depth cannot be determined; covered by slough or eschar

•DTPI: Deep Tissue Pressure Injury — non-blanchable purple or maroon intact skin

•Braden Scale: score 18 or below indicates at-risk; assess every shift

•Reposition every 2 hours; use pressure-redistribution mattress

⚡ Moist wound healing is preferred; irrigate with normal saline

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Pharmacology

Drug classifications, mechanisms, nursing considerations and toxicity management

•ACE Inhibitors (-pril): lisinopril, captopril

Side effects: dry cough (most common), hyperkalemia, angioedema (STOP immediately)

Contraindicated in pregnancy and bilateral renal artery stenosis

•ARBs (-sartan): losartan, valsartan — no cough; safe if ACE intolerant

•Beta Blockers (-olol): metoprolol, atenolol, carvedilol

Side effects: bradycardia, hypotension, fatigue; masks hypoglycemia in diabetics

Hold if HR below 60 or systolic below 90 mmHg

•Calcium Channel Blockers (-dipine): amlodipine, nifedipine — peripheral edema

•Loop Diuretics: furosemide (Lasix) — hypokalemia; give in morning

•K-sparing: spironolactone — hyperkalemia; avoid potassium supplements

⚡ Always check BP before giving; hold if systolic below 90 mmHg

•Heparin (IV or SQ):

Therapeutic aPTT: 60–100 seconds (1.5–2.5 times normal)

Antidote: Protamine sulfate

Monitor for HIT — Heparin-Induced Thrombocytopenia

•Warfarin (Coumadin):

Therapeutic INR: 2.0–3.0; mechanical valve 2.5–3.5

Antidote: Vitamin K (phytonadione); FFP for acute bleeding

•Enoxaparin (Lovenox): SubQ only; renally cleared; anti-Xa monitoring

•DOACs (direct oral anticoagulants):

Dabigatran antidote = idarucizumab (Praxbind)

Rivaroxaban or apixaban antidote = andexanet alfa

•Aspirin: irreversible platelet inhibition; give with food

•Clopidogrel (Plavix): hold 5–7 days before any surgery

•Penicillins: cross-reactivity with cephalosporins approximately 10%; verify allergy

•Fluoroquinolones (-floxacin): avoid in pregnancy and children; tendon rupture risk

•Aminoglycosides: gentamicin, tobramycin

NEPHROTOXIC and OTOTOXIC — monitor peak/trough levels; maintain hydration

•Vancomycin:

Red Man Syndrome: flushing and hypotension with rapid infusion — slow rate to 60–90 min

Monitor trough levels 15–20 mcg/mL; check renal function

•Metronidazole (Flagyl): avoid all alcohol — disulfiram-like reaction (nausea, vomiting, flushing)

•C. diff treatment: oral vancomycin or fidaxomicin (NOT IV vancomycin)

⚡ Always teach: complete the FULL antibiotic course even when feeling better

•Rapid-acting (Lispro, Aspart): onset 10–30 min; give right before or with meals

•Regular insulin: onset 30–60 min; CLEAR appearance; give 30 min before meals

•NPH (intermediate): onset 2–4h; peak 4–12h; CLOUDY appearance

•Glargine/Lantus (long-acting): no peak; once daily; CLEAR; do NOT mix with other insulins

•Mixing rule: draw CLEAR before CLOUDY (Regular before NPH)

•Metformin: first-line Type 2; hold 48h before IV contrast dye (lactic acidosis risk)

•Sulfonylureas (glipizide, glyburide): hypoglycemia risk; take with meals

•SGLT2 inhibitors (-gliflozin): genital yeast infections; UTI risk; hold before surgery

⚡ Hypoglycemia below 70 mg/dL: 15–15 Rule — 15g carbs, recheck in 15 minutes

•SSRIs (fluoxetine, sertraline): GI upset, sexual dysfunction, insomnia

Allow 2–4 weeks for full therapeutic effect

Serotonin syndrome: agitation, hyperthermia, tachycardia, clonus — EMERGENCY

•MAOIs: last resort; tyramine-free diet (aged cheese, red wine, cured meats, beer)

•Lithium (bipolar I):

Therapeutic level: 0.6–1.2 mEq/L; TOXIC above 1.5 mEq/L

Toxicity signs: tremor, N/V, diarrhea, confusion, ataxia

Dehydration or low sodium increases lithium level and toxicity risk

•Haloperidol (typical antipsychotic):

EPS: akathisia, dystonia, parkinsonism, tardive dyskinesia

Treat acute dystonia with diphenhydramine or benztropine IM/IV

•Clozapine: treatment-resistant schizophrenia; MANDATORY weekly CBC; agranulocytosis risk

•Opioid side effects: constipation (does NOT resolve), N/V, sedation, respiratory depression

•Respiratory depression: RR below 12 — hold opioid; give Naloxone (Narcan)

•PCA pump: nurse NEVER presses button for the patient

•Acetaminophen: maximum 4g/day; 2g/day for elderly or liver disease

•NSAIDs: GI bleeding risk; avoid in renal impairment, elderly, and pregnancy

•Ketorolac (Toradol): IV/IM NSAID; 5-day maximum; renal toxicity risk

•Adjuvants: gabapentin or pregabalin for neuropathic pain

⚡ Always believe the patient's pain report; use validated pain scales consistently

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Medical Surgical

Adult health nursing — cardiovascular, respiratory, neuro, renal and surgical care

•MI signs: chest pain (crushing/pressure), diaphoresis, N/V, dyspnea, jaw or left-arm radiation

Women may present atypically: fatigue, nausea, or epigastric pain

•STEMI: PCI within 90 minutes of arrival (door-to-balloon time)

•Troponin I/T: most specific marker; rises 3–6h, peaks 24h, normalizes 5–14 days

•MONA for ACS: Morphine, Oxygen, Nitroglycerin, Aspirin

•Heart Failure nursing:

Position HIGH Fowler's (60–90 degrees); O2 to maintain SpO2 above 95%

Daily weights: gain of 2+ lbs in 1 day = notify provider

Strict I&O; fluid restriction; low-sodium diet

•Digoxin therapeutic level: 0.5–2 ng/mL

Toxicity: bradycardia, yellow-green halos, N/V; antidote = Digibind

⚡ V-fib or pulseless V-tach: immediate unsynchronized defibrillation

•COPD: target SpO2 88–92%; O2 at 1–2 L/min; avoid over-oxygenating (hypoxic drive)

Signs: barrel chest, prolonged expiration, pursed-lip breathing, tripod position

•Pneumonia: HIGH Fowler's; deep breathing and coughing; hydration; incentive spirometry q1h

•VAP bundle: HOB 30–45 degrees, daily oral CHG care, sedation holiday

•Pulmonary Embolism:

Signs: sudden dyspnea, pleuritic chest pain, hemoptysis, tachycardia

Virchow's triad: venous stasis, hypercoagulability, endothelial injury

Treatment: anticoagulation; massive PE requires thrombolytics

•ABG normal values: pH 7.35–7.45, PaCO2 35–45, HCO3 22–26, PaO2 80–100

•ROME: Respiratory Opposite, Metabolic Equal

•Stroke — BE-FAST: Balance, Eyes, Face, Arm, Speech, Time

•Ischemic stroke tPA criteria: within 3–4.5 hours of onset; BP below 185/110 before giving

•Hemorrhagic stroke: NO tPA; BP management; surgery may be needed

•Cushing's Triad (raised ICP): widened pulse pressure + bradycardia + irregular respirations

•Raised ICP nursing:

HOB 30 degrees; neutral neck alignment; quiet environment; cluster care

Avoid Valsalva maneuver and straining

CPP = MAP minus ICP; goal CPP 70–100 mmHg; normal ICP 0–15 mmHg

•Seizure safety: lateral position, protect airway, do NOT restrain, time the seizure

•Status epilepticus (over 5 min): lorazepam IV is first-line treatment

•AKI phases: Oliguric (less than 400 mL/day), Diuretic (up to 10 L/day), Recovery

•CKD complications: anemia (decreased EPO), hyperkalemia, metabolic acidosis, hyperphosphatemia

•Hemodialysis fistula/graft:

NEVER take BP, start IV, or do venipuncture in that arm

Bruit and thrill must be present; report loss immediately

•Hyperkalemia ECG changes: peaked T waves, widened QRS, sine wave, then V-fib

•Hyperkalemia treatment sequence:

1. Calcium gluconate — stabilizes cardiac membranes (fastest action)

2. Insulin plus D50W — shifts K+ into cells

3. Kayexalate or patiromer — removes K+ from body

4. Dialysis for severe or refractory cases

•Pre-op: informed consent BEFORE any sedating medications

NPO: 8h for solid food; 6h for a light meal; 2h for clear liquids

Remove jewelry, dentures, contacts, hearing aids, nail polish

Verify allergies, medications, implants, and pregnancy if applicable

•Surgical time-out: confirm patient identity, procedure, site, and position

•Post-op PACU: Airway, then Breathing, then Circulation

•Post-op CMS checks distal to surgical site: Circulation, Motion, Sensation

•Complications prevention:

Atelectasis: incentive spirometry 10 times per hour; turn, cough, deep breathe

DVT: SCDs, early ambulation, anti-embolism stockings, anticoagulants

Wound dehiscence: sterile saline dressing; do NOT reinsert viscera; call provider STAT

Paralytic ileus: NPO; bowel sounds q4h; early ambulation

•DKA (Type 1 diabetes):

Glucose above 250, pH below 7.3, HCO3 below 18, ketones positive

Signs: Kussmaul respirations, fruity breath, polydipsia, polyuria, abdominal pain

Treatment in order: 1) IV 0.9% NS fluids 2) IV insulin drip 3) K+ (only if above 3.3)

•HHS (Type 2 diabetes): glucose above 600, no ketones, extreme dehydration

Treatment: aggressive IV fluid resuscitation; insulin infusion

•Thyroid storm: fever above 40°C, extreme tachycardia, agitation — EMERGENCY

Treatment: PTU first, then iodine 1h later, beta-blocker, steroids, cooling

•Adrenal crisis: hypotension, fever, N/V

Treatment: IV hydrocortisone 100 mg STAT plus 0.9% NS immediately

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Mental Health

Psychiatric nursing, therapeutic communication, mental disorders and crisis intervention

•USE — Therapeutic techniques:

Open-ended questions: 'What are you feeling right now?'

Reflection: 'It sounds like you feel overwhelmed.'

Clarification: 'Tell me more about that.'

Silence: allows patient to reflect; sit comfortably with them

Validation: 'That sounds very difficult.'

•AVOID — Non-therapeutic:

False reassurance: 'Don't worry, everything will be fine.'

Giving advice: 'You should...' or 'I think you need to...'

Minimizing: 'It could be worse.' or 'Others have it harder.'

Why questions: 'Why did you do that?' implies judgment

Changing the subject or deflecting the patient's concerns

⚡ ALWAYS ask directly about suicidal ideation — asking does NOT plant the idea

•Break confidentiality only for: intent to harm self or others; abuse of child or elder

•Major Depression — SIGECAPS (need 5+ symptoms for 2+ weeks):

Sleep changes, Interest loss, Guilt, Energy decrease, Concentration problems,

Appetite changes, Psychomotor changes, Suicidal ideation

•Bipolar I: full manic episodes 7+ days; Bipolar II: hypomania plus depression

•Mania: decreased sleep without fatigue, grandiosity, racing thoughts, impulsivity

•Antidepressants take 2–4 weeks for full effect

FDA black box warning: increased suicidality in patients under 25 in first 2 weeks

•Lithium monitoring:

Therapeutic: 0.6–1.2 mEq/L; TOXIC above 1.5 mEq/L

Toxicity: tremor, N/V, diarrhea, confusion, ataxia

Low sodium or dehydration raises lithium levels and toxicity risk

⚡ Priority nursing: SAFETY — assess ideation, plan, means, intent

•Anxiety levels:

Mild: learning and problem-solving intact

Moderate: narrowed perceptual field; needs guidance

Severe: disorganized; unable to function

Panic: terror; unable to communicate rationally

•Panic attack nursing: stay with patient; calm voice; simple direct instructions

•GAD: uncontrollable worry 6+ months; SSRIs plus CBT first-line

•PTSD: trauma plus re-experiencing plus avoidance plus hyperarousal for 1+ month

•OCD: obsessions (intrusive thoughts) plus compulsions (rituals); ego-dystonic

First-line: SSRIs plus Exposure and Response Prevention CBT

•Benzodiazepines: short-term only; dependence risk; antidote = flumazenil

⚡ Never leave patient alone during panic attack

•Positive symptoms (excess): hallucinations, delusions, disorganized speech

•Negative symptoms (absent): flat affect, alogia, avolition, anhedonia, social withdrawal

•Most common hallucination type: AUDITORY (hearing voices)

•Nursing approach to hallucinations:

Do NOT argue or validate them

Say: 'I don't hear that, but I can see you're frightened.'

Redirect to reality-based activities

•Nursing approach to delusions:

Do NOT argue or play along

Acknowledge the feeling; gently redirect

•Antipsychotics:

Typical (haloperidol): EPS, tardive dyskinesia; treat acute dystonia with benztropine

Atypical (olanzapine, risperidone): metabolic syndrome, weight gain

Clozapine: treatment-resistant cases; MANDATORY weekly CBC; agranulocytosis

•NMS: hyperthermia plus rigidity plus altered LOC — STOP antipsychotic immediately

•CAGE Questionnaire (2 or more yes answers = problem):

Cut down, Annoyed, Guilty, Eye-opener

•Alcohol Withdrawal Timeline:

6–24h: tremors, diaphoresis, anxiety, tachycardia

24–48h: SEIZURES — peak risk

48–72h: Delirium Tremens — hallucinations, autonomic instability

•CIWA-Ar scale: score above 8 indicates need for medication

•DT treatment: benzodiazepines (lorazepam, diazepam) — prevent seizures

⚡ Alcohol withdrawal CAN be fatal; opioid withdrawal is NOT life-threatening

•Opioid overdose: pinpoint pupils, respiratory depression, unconsciousness

Naloxone (Narcan): IM/IN/IV; may need repeated doses

•Wernicke's encephalopathy: give THIAMINE before glucose in alcoholic patients

•Always ask directly: 'Are you thinking about hurting yourself?'

•Assess: ideation, plan, means, intent, timeline

•Highest risk factors:

Previous attempt (STRONGEST predictor), male gender, elderly, chronic illness,

substance use, recent loss, access to firearms, hopelessness

•Protective factors: social support, religious beliefs, children at home, future plans

•Safety levels:

Close observation: checks every 15–30 minutes

Constant 1:1: nurse within arm's length at ALL times

•Environment: remove belts, cords, sharps, medications, and call light cords

•Involuntary holds: 72-hour hold for imminent danger (Baker Act or 5150)

•Crisis line: 988 Suicide and Crisis Lifeline (call or text)

⚡ Document all assessments using patient's exact words in quotation marks

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Maternal & Newborn

Maternity nursing, prenatal care, labor and delivery, postpartum and newborn assessment

•Naegele's Rule: LMP minus 3 months plus 7 days = estimated due date

•Normal weight gain: 25–35 lbs for normal BMI

•Visit schedule: q4 weeks until 28 wks; q2 weeks 28–36 wks; weekly after 36 wks

•First visit labs: CBC, blood type/Rh, rubella, HIV, VDRL/RPR, HepBsAg, urinalysis

•Positive signs (diagnostic): FHR by Doppler, fetal movement felt by examiner, ultrasound

⚡ DANGER signs — report immediately:

Vaginal bleeding, severe headache, visual changes, epigastric pain,

absent fetal movement, sudden gush of fluid (PROM)

•Stage 1 — Dilation:

Latent: 0–6 cm; mild contractions; teach breathing; ambulate if allowed

Active: 6–10 cm; stronger contractions q3–5 min; pain management offered

Transition: 8–10 cm; most intense; urge to push; do NOT push until complete

•Stage 2 — Pushing to Birth: push with contractions; rest between

•Stage 3 — Placental Delivery: up to 30 minutes; monitor for hemorrhage

•Stage 4 — Recovery 1–4 hours: q15 min VS, fundus, lochia, bladder assessment

•Normal FHR: 110–160 bpm

•Category III (abnormal): persistent late decels, absent variability, sinusoidal pattern

Action: notify MD immediately; prepare for delivery

•Baseline FHR: 110–160 bpm; bradycardia below 110; tachycardia above 160

•Accelerations: FHR 15+ bpm above baseline for 15+ seconds — REASSURING; confirms well-being

•Early decelerations: mirror contraction shape; head compression — NORMAL, no action

•Late decelerations: begin AFTER contraction peak; uteroplacental insufficiency

Interventions: left lateral position, O2 8–10 L/min mask, IV fluid bolus, stop oxytocin, notify MD

•Variable decelerations: abrupt onset; cord compression

Interventions: reposition (knee-chest or lateral), O2, amnioinfusion if ordered

•Sinusoidal pattern: smooth sine wave; severe fetal anemia — EMERGENCY

•B — Breasts: engorgement, nipple cracking, mastitis signs (fever, redness, warmth)

•U — Uterus: firm, midline, at umbilicus; descends 1 fingerbreadth per day

Boggy uterus: massage until firm; assess for hemorrhage

•B — Bowel: first BM within 2–3 days; stool softeners; fluids and fiber

•B — Bladder: void within 6–8h of delivery; catheterize if unable

•L — Lochia:

Rubra: red, 1–3 days; Serosa: pink, 4–9 days; Alba: white, 10–14 days

Saturating more than 1 pad per hour = HEMORRHAGE; notify provider

•E — Episiotomy: ice packs first 24h; sitz baths after; assess REEDA

•L — Lower extremities: assess for DVT signs; edema, pain, warmth

•E — Emotions: baby blues (3–5 days) vs PPD (persists beyond 2 weeks; needs treatment)

•APGAR Score at 1 minute and 5 minutes:

Appearance, Pulse, Grimace, Activity, Respiration — each scored 0–2

Score 7–10 normal; 4–6 moderate depression; 0–3 severe depression

•Normal newborn vital signs: HR 120–160, RR 30–60, Temp 36.5–37.5°C

•Head circumference: 33–35 cm; chest 30–33 cm (head larger by about 2 cm)

•Birth medications: Vitamin K (hemorrhagic disease prevention) + erythromycin eye ointment

•Normal newborn reflexes: Moro, Rooting, Sucking, Palmar grasp, Babinski (present = NORMAL)

•First void: within 24h; first meconium stool: within 24–48h

⚡ Hypoglycemia risk: LGA, SGA, preterm, infant of diabetic mother — screen at 1–2h of life

•Preeclampsia: BP 140/90 or higher on 2 occasions 4h apart after 20 weeks plus proteinuria

•Severe: BP 160/110 or higher, headache, visual changes, RUQ pain, thrombocytopenia

•HELLP: Hemolysis, Elevated Liver enzymes, Low Platelets — medical emergency

•Eclampsia: new-onset seizure in preeclamptic patient

•MgSO4 therapy:

Therapeutic level: 4–7 mEq/L

Toxicity signs: absent DTRs (first sign), RR below 12, oliguria below 30 mL/hr

ANTIDOTE: calcium gluconate 1g IV — keep at bedside at ALL TIMES

Monitor DTRs, RR, and urine output every hour

⚡ Delivery is the ONLY CURE for preeclampsia

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Pathophysiology

Disease mechanisms, acid-base balance, shock and immune responses

•Normal ABG values: pH 7.35–7.45, PaCO2 35–45 mmHg, HCO3 22–26 mEq/L

•Step-by-step interpretation:

1. Is pH below 7.35 (acidosis) or above 7.45 (alkalosis)?

2. Is PaCO2 the problem? Above 45 = respiratory acidosis; below 35 = respiratory alkalosis

3. Is HCO3 the problem? Below 22 = metabolic acidosis; above 26 = metabolic alkalosis

4. Check for compensation: does the other system move in the same direction as pH?

•ROME mnemonic: Respiratory Opposite, Metabolic Equal

•Metabolic acidosis causes — MUDPILES:

Methanol, Uremia, DKA, Propylene glycol, Isoniazid/Iron, Lactic acidosis, Ethylene glycol, Salicylates

•Respiratory acidosis: hypoventilation — COPD, opioid overdose, sedation

•Respiratory alkalosis: hyperventilation — anxiety, pain, PE, fever, altitude

•Metabolic alkalosis: vomiting, NG suction, antacid overuse, hypokalemia

•Hypovolemic: decreased blood volume; hemorrhage, burns, dehydration

Signs: tachycardia, hypotension, decreased UO, pale/cool/clammy skin

Treatment: IV fluid resuscitation; identify and control source of loss

•Cardiogenic: pump failure; MI, severe HF, dysrhythmias

Signs: JVD, crackles, S3 gallop, narrow pulse pressure

Treatment: inotropes (dobutamine), vasopressors, treat underlying cause

•Distributive (vasodilation):

Septic: most common; early warm/flushed, late cold/clammy

Anaphylactic: EPINEPHRINE 0.3 mg IM thigh FIRST; then O2, antihistamine, steroids

Neurogenic (spinal cord): bradycardia plus hypotension WITHOUT compensatory tachycardia

•Obstructive (mechanical block):

Tension pneumothorax: tracheal deviation, absent breath sounds; needle decompression

Cardiac tamponade: Beck's triad — hypotension, JVD, muffled heart sounds; pericardiocentesis

•Cardinal signs: Redness, Warmth, Swelling, Pain, Loss of function

•Acute inflammation: under 2 weeks; neutrophils predominate

•Chronic inflammation: over 2 weeks; macrophages and lymphocytes; granuloma formation

•Innate immunity (non-specific): skin barriers, phagocytes, NK cells, complement, fever

•Adaptive immunity (specific, acquired):

Humoral — B cells: antibody production (IgG, IgM, IgA, IgE, IgD)

Cell-mediated — T cells: CD4+ helpers and CD8+ cytotoxic T cells

•Hypersensitivity types:

Type I (IgE, immediate): anaphylaxis, asthma, allergic rhinitis

Type II (cytotoxic): blood transfusion reactions, Graves' disease

Type III (immune complex): SLE, serum sickness, glomerulonephritis

Type IV (delayed, cell-mediated): PPD skin test, contact dermatitis, transplant rejection

•HIV: destroys CD4+ T cells; AIDS defined as CD4 below 200/µL

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Pediatrics

Child health nursing, development milestones, pediatric diseases and immunizations

•Infant (0–12 months):

2 months: social smile, head up briefly

4 months: rolls front-to-back, reaches for objects, laughs

6 months: sits with support, transfers objects, stranger anxiety begins

9 months: crawls, pincer grasp developing, waves bye-bye

12 months: walks (up to 15 months is normal); 1–2 meaningful words

•Toddler (1–3 years):

18 months: 10+ words, parallel play

2 years: 2-word phrases; Erikson: Autonomy vs Shame and Doubt

3 years: 3–4 word sentences; associative play; rides tricycle

•Preschool (3–6 years): cooperative play begins; Initiative vs Guilt; magical thinking

•School-age (6–12 years): logical thinking; Industry vs Inferiority; peer relationships

•Adolescent (12–18 years): abstract reasoning; Identity vs Role Confusion

•Normal vital signs by age:

Newborn: HR 120–160, RR 30–60, BP 60–80/40–50

Infant 1–12m: HR 80–140, RR 24–40, BP 70–100/50–70

Toddler 1–3yr: HR 80–130, RR 20–30, BP 80–110/50–80

Preschool 3–6yr: HR 80–120, RR 20–25, BP 80–110/50–80

School-age 6–12yr: HR 70–110, RR 18–22, BP 85–120/55–80

Adolescent: HR 55–105, RR 12–18, BP 90–140/50–90

⚡ Respiratory rate is the MOST SENSITIVE indicator of distress in children

•Pain scales:

NIPS: neonates; FLACC: 0–7 years (Face, Legs, Activity, Cry, Consolability)

Wong-Baker FACES: 3+ years; Numeric 0–10: 7+ years

•Fever: above 38°C (100.4°F); treat with acetaminophen 10–15 mg/kg

⚡ AVOID aspirin in children — risk of Reye's syndrome

•Birth: HepB #1

•2 months: DTaP, Hib, IPV, PCV13, Rotavirus, HepB #2

•4 months: DTaP, Hib, IPV, PCV13, Rotavirus

•6 months: DTaP, PCV13, HepB #3; start Influenza yearly from 6 months

•12–15 months: MMR #1, Varicella #1, Hib, PCV13, HepA #1

•4–6 years: DTaP, IPV, MMR #2, Varicella #2

•11–12 years: Tdap, MenACWY, HPV series

•Live vaccines (CANNOT give to immunocompromised):

MMR, Varicella, Rotavirus, LAIV (intranasal flu)

•Contraindications: anaphylaxis to previous dose or vaccine component

⚡ Febrile seizure may occur post-MMR (5–12 days); does NOT prevent future vaccines

•Croup (Laryngotracheobronchitis):

Age 6m–3yr; parainfluenza virus; worse at night

Signs: barking seal cough, inspiratory stridor, mild fever, hoarse voice

Treatment: cool humidified air; dexamethasone; racemic epinephrine for severe cases

Steeple sign on X-ray (subglottic narrowing)

•Epiglottitis — MEDICAL EMERGENCY:

Signs: HIGH fever above 39°C, severe drooling, tripod position, muffled voice

DO NOT examine the throat; keep child calm; do NOT lay child flat

Prepare for immediate intubation; IV antibiotics (ceftriaxone)

Thumb sign on lateral neck X-ray

•RSV Bronchiolitis: infants under 2 years; wheezing and crackles; supportive care

•Key difference: Epiglottitis = sudden high fever, drooling, prefers sitting; Croup = gradual, barking

•Holliday-Segar maintenance fluids:

First 10 kg: 100 mL/kg/day

Next 10 kg (10–20 kg): 50 mL/kg/day

Each kg above 20 kg: 20 mL/kg/day

Example: 25 kg child = 1000 + 500 + 100 = 1600 mL/day

•Always calculate mg/kg; compare to maximum adult dose

•Acetaminophen: 10–15 mg/kg q4–6h; maximum 5 doses per 24 hours

•Ibuprofen: 5–10 mg/kg q6–8h; only for children 6 months of age and older

•AVOID in children: Aspirin (Reye's syndrome); tetracyclines under 8yr; fluoroquinolones under 18yr

•Dehydration:

Mild (less than 5%): increased thirst, slightly dry mucous membranes

Moderate (5–10%): sunken eyes, decreased tears, poor skin turgor

Severe (over 10%): sunken fontanelle, no tears, hypotension, tachycardia — IV fluids urgently

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Adult Health

Chronic and acute adult conditions — musculoskeletal, GI and endocrine nursing

•Fracture types:

Closed (simple): skin intact

Open (compound): bone through skin; high infection risk

Comminuted: multiple fragments

Pathological: through diseased bone (cancer, osteoporosis)

•Compartment Syndrome — 5 P's:

Pain (OUT OF PROPORTION — earliest sign), Pressure, Pallor, Paresthesia, Pulselessness

EMERGENCY: release cast or splint; prepare for fasciotomy; do NOT elevate the limb

•Cast care: elevate above heart; CMS checks every 1–2h (Circulation, Motion, Sensation)

•Total Hip Replacement posterior approach:

No hip flexion greater than 90 degrees

No internal rotation of operative leg

No adduction of operative leg past midline

•Osteoporosis: DEXA T-score at or below negative 2.5

Bisphosphonates: take in AM on empty stomach; stay upright for 30–60 min

•GERD: elevate HOB 30 degrees; avoid food 3h before bed; lose weight; avoid triggers

•PUD (Peptic Ulcer Disease):

H. pylori most common cause; triple therapy: PPI + clarithromycin + amoxicillin for 10–14 days

Perforation: sudden severe epigastric pain, rigid abdomen — SURGICAL EMERGENCY

•GI Bleeding:

Upper GI: hematemesis, coffee-ground emesis, melena (black tarry stools)

Lower GI: hematochezia (bright red blood per rectum)

Priority: large-bore IV access x2, fluid resuscitation, type and crossmatch, NPO

•Liver Cirrhosis complications:

Portal hypertension to varices to hemorrhage (octreotide plus sclerotherapy)

Ascites: fluid and sodium restriction; spironolactone plus furosemide

Hepatic encephalopathy: lactulose (goal 2–4 soft stools/day); rifaximin

•Pancreatitis: NPO, IV fluids, pain control; Cullen sign (periumbilical); Grey Turner (flank)

•Crohn's vs UC: Crohn's = anywhere GI tract, skip lesions, all layers; UC = colon only, continuous, mucosal

•Hypothyroidism: weight gain, fatigue, cold intolerance, bradycardia, constipation

Treatment: levothyroxine; take in AM on empty stomach

•Hyperthyroidism (Graves' disease): weight loss, heat intolerance, tachycardia, exophthalmos

Treatment: PTU or methimazole; beta-blockers; radioactive iodine; surgery

•Thyroid storm: EMERGENCY — fever above 40°C, extreme tachycardia, agitation

•Cushing's syndrome: moon face, buffalo hump, central obesity, purple striae, hyperglycemia

Most common cause: long-term corticosteroid therapy

•Addison's disease: cortisol deficiency

Signs: bronze skin, hypotension, hyperkalemia, hyponatremia, weight loss

Adrenal crisis: IV hydrocortisone plus 0.9% NS — treat IMMEDIATELY

•SIADH: excess ADH causes dilutional hyponatremia

Treatment: fluid restriction; correct sodium slowly to prevent osmotic demyelination

🧒

Child Health

Child health promotion, family-centered care and congenital conditions

•Family-centered care principles:

Family as essential irreplaceable part of the healthcare team

Honest and complete information sharing with families

Respect for family strengths and cultural diversity

Collaboration in all levels of care planning

•Atraumatic care:

Prevent or minimize physical and psychological distress

EMLA or LMX4 cream before venipuncture (apply 60 min before)

Therapeutic play before and after procedures

Allow parent presence during procedures when possible

Use sucrose pacifier for infants during painful procedures

•Developmental approach to procedures:

Toddler/Preschool: explain just before; use puppets or dolls

School-age: explain HOW it will feel; provide choices when safe

Adolescent: explain WHY; ensure privacy; involve in decisions

•Child Life Specialists: therapeutic play; procedure preparation; sibling support

•Acyanotic defects (Left to Right shunt):

Oxygenated blood recirculates through lungs; leads to pulmonary hypertension over time

VSD (most common CHD overall): holosystolic murmur; many close spontaneously

ASD: wide fixed split S2; surgical closure if large or symptomatic

PDA: machinery murmur; indomethacin closes in preterm infants; prostaglandins keep open

•Cyanotic defects (Right to Left shunt):

Deoxygenated blood bypasses lungs; central cyanosis not relieved by oxygen alone

Tetralogy of Fallot (most common cyanotic CHD):

4 defects: VSD, pulmonary stenosis, overriding aorta, RV hypertrophy

Boot-shaped heart on chest X-ray

Tet spell: hypercyanosis with crying — KNEE-CHEST position + O2 + morphine

Transposition of Great Arteries: aorta from RV; prostaglandin E1 keeps PDA open; surgical switch

•CHF in infants: poor feeding, diaphoresis with feeding, tachypnea, failure to thrive

•Physical abuse indicators:

Patterned bruises or burns inconsistent with developmental stage

Multiple fractures in different stages of healing

Delay in seeking medical care; inconsistent history

•Shaken Baby Syndrome: retinal hemorrhage plus subdural hematoma with no external signs

•Sexual abuse indicators:

STI in a young child; age-inappropriate sexual knowledge or behaviors

•Neglect: poor hygiene, malnutrition, untreated medical conditions

•Mandatory reporting: nurses are LEGALLY REQUIRED to report suspected abuse

Suspicion alone is sufficient — you do NOT need proof

Report to child protective services; follow facility policy

•Documentation: objective and factual; record the child's exact words in quotes

Use body diagrams to document injury locations

⚡ Priority: ensure child SAFETY first; do NOT confront the suspected abuser directly