Always prioritize Airway, Breathing, and Circulation in that order. A patient with an airway issue needs immediate attention before addressing other concerns, even if they seem urgent. Remember that a patient without an airway won't benefit from any other interventions.
When prioritizing care, remember physiological needs come first, followed by safety. Address breathing issues before addressing a patient's concerns about their personal belongings. This framework helps organize multiple competing patient needs.
Memorize these antidote pairs: Naloxone for opioids, Flumazenil for benzodiazepines, Protamine for heparin, Vitamin K for warfarin, and Acetylcysteine for acetaminophen toxicity. Quick recall of these pairs can be life-saving in emergency situations.
Always double-check the 'rights' of medication administration for high-alert meds like insulin, anticoagulants, and opioids. These medications have a higher risk of causing significant patient harm when used in error and require extra vigilance during preparation and administration.
Remember HELLP syndrome: Hemolysis, Elevated Liver enzymes, Low Platelets. Other warning signs include headache, visual changes, epigastric pain, and sudden edema. Early recognition and prompt intervention are critical to prevent progression to eclampsia.
First stage: latent (0-3cm), active (4-7cm), transition (8-10cm). Second stage: pushing to delivery. Third stage: placental delivery. Fourth stage: 1-2 hours postpartum recovery. Each stage requires different nursing interventions and support techniques.
Always address airway problems first (e.g., choking, stridor, low O2 sat). Use ABCs to guide priorities.
Maslow's hierarchy helps prioritize: Physical needs > Safety > Love/Belonging > Esteem > Self-Actualization.
Trough = drawn 30 min before dose; Peak = drawn 1–2 hrs after dose. Used to monitor narrow therapeutic drugs like vancomycin.
Statins, calcium channel blockers, and some psych meds interact with grapefruit juice. Teach patients to avoid.
Confusion, weakness, sedating meds, and previous falls increase fall risk. Use bed alarms, hourly rounding, non-skid socks.
Restraints are a last resort. Provider must renew order q24h, and nurse must assess every 15–30 min depending on policy.
Avoid 'why' questions — they can sound judgmental. Use open-ended phrases like 'Tell me more about…'
Don't reinforce or argue. Say: 'I don't see what you see, but I understand it feels real to you.'
From 20–36 weeks, fundal height in cm ≈ gestational age in weeks. Example: 30 weeks → 30 cm.
Signs: ↓ reflexes, ↓ RR, ↓ urine output. Antidote: Calcium gluconate.
Normal K+ = 3.5–5.0 mEq/L. High = cardiac risk. Low = weakness, cramps, arrhythmias.
INR above 3.0 = high bleed risk (on warfarin). Normal: 0.8–1.2. Therapeutic: 2–3 for most cases.
WBC <4,000 = neutropenia, high infection risk. Place on protective precautions if needed.
No head control by 4 months = concern. Refer for evaluation if missed milestones persist.
Hep B at birth. DTaP, Hib, IPV, PCV at 2, 4, 6 months. MMR and Varicella start at 1 year.
In COPD, keep O2 sat 88–92%. High oxygen can reduce respiratory drive.
Crackles, SOB, cough = left-sided heart failure. Right-sided = edema, ascites.
Order: Gown → Mask → Goggles → Gloves. Remember: Go, Make, Good, Gloves.
C. diff, MRSA, RSV = contact precautions. Use gown + gloves. Clean equipment between uses.
Always prioritize acute over chronic. A new-onset issue is more urgent than a stable, long-term condition.
Stable vital signs, routine meds, and discharge teaching are often lowest priority.
Watch for nausea, blurred vision, and bradycardia — these may indicate digoxin toxicity.
Draw up clear (Regular) insulin before cloudy (NPH). R → N = Right → Nowhere near wrong.
Right patient, drug, dose, route, time, and documentation. Triple-check during med pass.
Check circulation, skin integrity, and psychological status regularly. Document everything.
Ask directly: 'Are you thinking of hurting yourself?' Open conversation saves lives.
Acknowledge what they feel: 'That sounds scary. I don't see what you do, but I'm here to help you feel safe.'
Early = head compression (normal); Late = uteroplacental insufficiency (bad). Late = LION: Left side, IV fluids, O₂, Notify.
BP > 140/90 + proteinuria + swelling = danger. Headache and vision changes = worsening condition.
They may cry, point, or say 'owie' but also withdraw or act unusually. Assess with faces scale.
Appears around 6–9 months. It's normal. Encourage comfort from caregivers.
Normal = 0.6–1.2 mg/dL. High = impaired kidney function. Check med dosing closely.
Platelets <50,000 = risk for spontaneous bleeding. Avoid IMs and invasive procedures.
No tidaling = concern (check for blockage). Continuous bubbling = air leak.
High Fowler's = max lung expansion. Use it for dyspnea, fluid overload, pneumonia, or asthma.
Closed drainage systems (e.g., JP, chest tube) must stay sealed. No disconnections without sterile technique.
Use contact precautions — gloves + gown. Clean all equipment between patients.
Clients can refuse any treatment. Your job is to educate, assess understanding, and notify the provider.
Advance directives are general. A DNR must be a **specific** provider order in the chart.
Start at age 45 (earlier if family history). Colonoscopy every 10 years is standard.
Low sodium, low fat, low cholesterol. Focus on lean protein, whole grains, veggies.
Reposition q2h, use barrier creams, keep sheets wrinkle-free. Moisture = risk.
Cluster care, dim lights, reduce noise. Prioritize sleep for post-op and critically ill clients.
Red = immediate; Yellow = delayed; Green = minor; Black = expectant. Prioritize life-threatening but treatable cases first.
DKA = Type 1, acidosis, Kussmaul breathing. HHS = Type 2, no ketones, more dehydration. Both = treat with fluids + insulin.
Retains water → low sodium, low urine output, confusion. Treat with fluid restriction, hypertonic saline if needed.
HOB 30° to reduce ICP. Avoid flexing the neck. Position on unaffected side if at risk for aspiration.
F – Face droop, A – Arm drift, S – Speech slurred, T – Time to call 911. Quick action saves brain.
G = pregnancies, T = full term, P = preterm, A = abortions/miscarriages, L = living children.
Rubra (red) 1–3 days, Serosa (pink/brown) 4–10 days, Alba (white/yellow) up to 6 weeks.
No smoking signs. No petroleum-based products near O2. Avoid wool blankets (static spark!).
Remove loose rugs, add grab bars, light walkways, and encourage shoes with grip soles.
Hyperactivity, pressured speech, risky behaviors, sleeplessness. Keep environment low-stim.
Common ones: denial, projection, displacement, regression. Recognizing them helps guide therapeutic communication.
UAP can: bathe, feed stable clients, ambulate, measure vitals, and perform hygiene tasks. No assessments or teaching.
LPNs can reinforce teaching, do sterile dressing changes, monitor IV flow (not push meds), and care for stable patients.
Use contact + droplet precautions. Suctioning may be needed. Give fluids. High-risk infants may need Synagis.
Holds head up, follows with eyes, coos, smiles socially. If missing, follow up.
Must report any suspected drug/alcohol use to the charge nurse or supervisor immediately — protect the patient.
Must be read back to provider and documented clearly. Only use when urgent or provider is unavailable to chart.
Sit upright 90°, small bites, no straws, tuck chin when swallowing. Suction at bedside.
Includes water, broth, tea, Jell-O, clear juice, popsicles. Avoid dairy or pulp.
Left = Lung: crackles, dyspnea. Right = Rest of body: edema, JVD, ascites.
Morphine, Oxygen, Nitroglycerin, Aspirin. Not always in order — assess first, give ASAP.
It's a rescue inhaler. Use first during asthma attack. Can cause tachycardia or jitteriness.
Small, frequent meals. High protein & calories. Avoid gas-producing foods.
Keep drainage bag below bladder. Clean perineal area daily. Secure tubing. Don't allow loops or backflow.
Less than 30 mL/hr = kidney perfusion issue. Notify provider immediately.
MMR, Varicella, and intranasal flu = live vaccines. Don't give to immunocompromised or pregnant clients.
Dry, persistent cough is a common side effect of ACE inhibitors (like lisinopril). May switch to ARB instead.
Heparin = fast, IV/SQ, monitor aPTT. Warfarin = slow, oral, monitor INR. Use together for overlap.
Cold, clammy, shaky, confused, sweaty = low blood sugar. Give 15g carbs ASAP.
Airway > bleeding > infection. Always assess for airway obstruction, bleeding, and O2 sat first.
Protect airway, turn to side, pad rails, time it. Don't restrain or place anything in mouth.
Use high-fiber diet, small steps, thickened liquids, fall prevention. Monitor swallowing closely.
Reactive = good (2+ fetal movements with accelerations in 20 mins). Nonreactive = further testing.
Watch for hypotension. Preload with IV fluids and monitor BP closely after placement.
Double birth weight by 6 months, triple by 1 year. Failure may indicate malnutrition or chronic illness.
First teeth around 6 months. Use cold teething rings, clean gums gently, no honey before age 1.
Loud noises, anniversaries, or smells may trigger flashbacks. Encourage grounding techniques.
Lack of empathy, deceit, impulsivity, often manipulative. Set firm, consistent boundaries.
Airborne precautions. Negative pressure room. N95 mask. Keep door closed.
Reverse isolation: private room, no fresh flowers or raw food, mask visitors, hand hygiene is critical.
Rescue → Alarm → Contain → Extinguish. Always evacuate patients in immediate danger first.
Do Not Resuscitate = no CPR if heart or breathing stops. Still give meds, comfort, and care.
Men: 13–17 g/dL, Women: 12–16. Low = anemia, bleeding. High = dehydration or polycythemia.
<120 or >160 mEq/L = neuro changes, seizure risk. Normal = 135–145.
Irregular rhythm → blood pools → risk for stroke. Anticoagulation often needed (warfarin).
Low activity first 24 hrs, avoid heavy lifting, give stool softeners, heart-healthy diet starts immediately.
Cold = inflammation/swelling. Heat = muscle tension/pain. Limit to 15–20 minutes to avoid injury.
Close eyes, position body flat, remove lines unless autopsy. Clean, respect cultural rituals.
Only the provider explains risks/benefits. The nurse witnesses signature and ensures understanding.
Always use 2 identifiers — name + DOB — before any medication, treatment, or transport.
Chest pain = red tag (immediate), closed fracture = yellow (delayed), minor cuts = green, no pulse = black.
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