DO NOT delegate what you can EAT!
E - evaluate A - assess T - teach
addisons= down, down down up down
cushings= up up up down up
addisons= hyponatremia, hypotension, decreased blood vol, hyperkalemia, hypoglycemia
cushings= hypernatremia, hypertension, incrased blood vol, hypokalemia, hyperglycemia
No Pee, no K (do not give potassium without adequate urine output) EleVate Veins; dAngle Arteries for better perfusion
A= appearance (color all pink, pink and blue, blue [pale])
P= pulse (>100, < 100>
G= grimace (cough, grimace, no response)
A= activity (flexed, flaccid, limp) R= respirations (strong cry, weak cry, absent)
TRANSMISSION-BASED PRECAUTIONS:
AIRBORNE
My - Measles
Chicken - Chicken Pox/Varicella
Hez - Herpez Zoster/Shingles TB
or remember...
MTV=Airborne
Measles TBVaricella-Chicken Pox/Herpes Zoster-Shingles
Private Room - negative pressure with 6-12 air exchanges/hr
Mask, N95 for TB
DROPLET
think of SPIDERMAN!
S - sepsis
S - scarlet fever
S - streptococcal pharyngitis
P - parvovirus B19
P - pneumonia
P - pertussis
I - influenza
D - diptheria (pharyngeal)
E - epiglottitis
R - rubella
M - mumps
M - meningitis
M - mycoplasma or meningeal pneumonia
An - Adenovirus
Private Room or cohort
Mask
1
CONTACT PRECAUTION
MRS.WEE
M - multidrug resistant organism
R - respiratory infection
S - skin infections *
W - wound infxn
E - enteric infxn - clostridium difficile
E - eye infxn - conjunctivitis
SKIN INFECTIONS
VCHIPS
V - varicella zoster
C - cutaneous diphtheria
H - herpez simplex
I - impetigo
P - pediculosis
S - scabies
1. Air/Pulmonary Embolism (S&S: chest pain, difficulty breathing, tachycardia, pale/cyanotic,
sense of impending doom) --> turn pt to left side and lower the head of the bed.
2. Woman in Labor w/ Un-reassuring FHR (late decels, decreased variability, fetal
bradycardia, etc) --> turn on left side (and give O2, stop Pitocin, increase IV fluids)
3. Tube Feeding w/ Decreased LOC --> position pt on right side (promotes emptying of the
stomach) with the HOB elevated (to prevent aspiration)
4. During Epidural Puncture --> side-lying
5. After Lumbar Puncture (and also oil-based Myelogram)--> pt lies in flat supine (to prevent
headache and leaking of CSF) 6. Pt w/ Heat Stroke --> lie flat w/ legs elevated
7. During Continuous Bladder Irrigation (CBI) --> catheter is taped to thigh so leg should be
kept straight. No other positioning restrictions. 8. After Myringotomy --> position on side of affected ear after surgery (allows drainage of
secretions) 9. After Cataract Surgery --> pt will sleep on unaffected side with a night shield for 1-4 weeks. 10. After Thyroidectomy --> low or semi-Fowler's, support head, neck and shoulders. 11. Infant w/ Spina Bifida --> position prone (on abdomen) so that sac does not rupture 12. Buck's Traction (skin traction) --> elevate foot of bed for counter-traction
13. After Total Hip Replacement --> don't sleep on operated side, don't flex hip more than 45-
60 degrees, don't elevate HOB more than 45 degrees. Maintain hip abduction by separating
thighs with pillows. 14. Prolapsed Cord --> knee-chest position or Trendelenburg
Category | NCLEX EXAM |
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