NCLEX Prep Packet PDF

# Disaster Triage ## Red Tag (Class I) - Immediate threat to life → treat right away - Airway obstruction → Red tag - Requires immediate attention → Red tag - Shock → Red tag - Profound hemorrhage → Red tag ## Yellow (Class II) - Major injuries that require treatment → can wait 1-2 hrs - Need treatm...

# Disaster Triage ## Red Tag (Class I) - Immediate threat to life → treat right away - Airway obstruction → Red tag - Requires immediate attention → Red tag - Shock → Red tag - Profound hemorrhage → Red tag ## Yellow (Class II) - Major injuries that require treatment → can wait 1-2 hrs - Need treatment within 30mins - 2 hrs → - Open fracture → ## Green Tag (Class III or Nonurgent) - Minor injuries that don't need immediate treatment → can wait 2-4 hrs - "Walking wounded" → Green tag - Closed fracture → Green tag - Contusions → Green tag - Treatment can be delayed more than 2 hrs → Green tag ## Black Tag (Class IV or Expectant) - Expected and allowed to die → prepare for morgue - Cardiac arrest → Black tag # Lab Values - Sodium (Na) 135-145 - Potassium (K) 3.5-5.0 - Calcium (Ca) 8.6-10.2 - Magnesium (Mg) 1.3-2.3 - Chloride (CI) 97-107 - Phosphorous (P) 2.5-4.5 - Creatinine 0.6-1.2 - BUN 10-20 - Glucose 70-110 # Other Lab Values - WBC 5,000-10,000 - ANC < 1000 = neutropenic precautions - RBC 3.2-5.4 - Hgb 12-18 - Hct (always 3x the amt of Hgb) 36-54 - Platelets 150,000-400,000 - PT (think age of pre-teen) Normal: 11-13 - Warfarin: multiply by 1.5 - 2.5 - INR Normal: 0.8-1.1 - Warfarin: 2-3 (multiply by 1.5-2.5) - aPTT Normal: 30-40 - Heparin: 45-70 (multiply by 1.5-2.5) - Antidote: Vitamin K - Antidote: Vitamin K - Antidote: Protamine Sulfate - PT/INR/aPTT are tests to measure how long it takes blood to clot - Anticoagulants the results should be longer = taking more time for a blood clot to form. # Other Vital Signs - PH 7.35-7.45 - HCO3 22-26 - PaCO2 35-45 - PaO2 80-100 # Acid-Base Balance - **Respiratory Acidosis** 7.35 LOW & ↑ 35-35 NORMAL - **Metabolic Acidosis** 7.35 LOW & 22 LOW - **Respiratory Alkalosis** ↑ 7.45 HIGH & 35 LOW - **Metabolic Alkalosis** ↑ 7.45 HIGH & ↑ 26 HIGH - Compensated = pH normal, paCO2 and HCO3 both abnormal - Partially compensated = everything abnormal - Uncompensated = pH abnormal, either paCO2 or HCO3 is abnormal # Urine Specific Gravity - Tests the concentration/amt of particles in your urine. - 1.010-1.030 - ↓ = dilute urine = concentrated urine (dehydration) # Albumin - 3.4 - 5 # PSA (Prostate Specific Antigen) - Levels must be drawn 48hrs after digital rectal exam otherwise they will be falsely elevated - Levels artificially lowered by saw palmetto # Troponin I (rises within 3 hrs and persists 7-10 days) - < 0.4 # Troponin T - < 0.6 = normal - > 1.5 = MI # BNP - > 0.2 = MI - > 100 = HF # ESR - 0-20 # HDL - > 40-60 # LDL - < 130 # Triglycerides - < 150 # Cholesterol - < 200 # AST & ALT - 8-20 # HbA1C - Normal: 4-6% - Diabetes: > 6.5% -- (Current blood sugar & time of test doesn't affect results) 3-5ml of blood is needed CANNOT USE A FINGERSTICK # Fasting Blood Glucose - Normal: 70-110 - Pregnant: < 95 # Glucose Tolerance Test (Performed @ 24 wks of pregnancy) - Fasting: 95 - 1 hour: if > 140 requires more testing - 3 hour: 2 or more levels met/exceeded = diabetes - 1 hour: 180 - 2 hour: 155 - 3 hour: 140 # Medications - Digoxin (Lanoxin) 0.5-2 - Lithium (Lithobid) 0.8-1.2 - Toxic: > 1.5 - Antidote: Digibind - Gentamicin 5-10 - Phenytoin (Dilantin) 10-20 - Theophylline 10-20 - Phenobarbital 10-30 - Magnesium Sulfate 4-8 - Aspirin (Salicylates) 15-30 - Antidote: Vitamin K - Warfarin (Coumadin) - Antidote: Vitamin K - Heparin - Antidote: Protamine Sulfate - Digoxin - Antidote: Digibind - Acetaminophen - Antidote: Mucomyst - Benzodiazepines - Antidote: Flumazenil - Opioids - Antidote: Narcan (Naloxone) - Calcium Channel Blockers - Antidote: Glucagon - Beta Blockers - Antidote: Glucagon - Magnesium Sulfate - Antidote: Calcium gluconate - Extra Pyramidal Symptoms (EPS) - Antidote: Cogentin (Benztropine), Benadryl # Electrolyte Imbalances ## Hyponatremia <135 - Nausea/diarrhea - Muscle cramps/twitching/convulsions - ICP - Confusion - Weakness - Headache ## Hypokalemia <3.5 - Muscle weakness/parasthesias ## Hypernatremia >145 - Skin flushed - Agitated - Thirst, dry tongue - Confusion - Low grade fever - Thirst (dry, swollen tongue) - Tachycardia - Hypotension ## Hyperkalemia >5 - EKG changes/dysrhythmias/cardiac arrest - Nausea # Calcium Imbalances ## Hypocalcemia <8.6 - **Think CATS** - Chovstek's Sign: tap facial nerve by ear → tetany/spasms of all facial muscles - Arrhythmias - Trousseau's Sign/Tetany: BP cuff inflated 20mmHg over systolic & held for 3 mins → carpal tetany/spasms - Seizures/spasms - Dysrhythmias ## Hypercalcemia >10.2 - Sedative effect on CNS - Depressed DTR's - Muscle weakness - Abdominal pain/distention - Dysrhythmias - TRIPPING OVER THEIR FEET (CAN'T WALK RIGHT) # Magnesium Imbalances ## Hypomagnesemia <1.3 - Tetany/tremors - Dysrhythmias - Dysphagia - Confusion ## Hypermagnesemia >2.3 - CNS depression - Shallow respirations - Depressed DTR's - Hypotension - Facial flushing # Endocrine Imbalances ## Cushing's Syndrome - Pituitary gland produces too much cortisol (hydrocortisone) - **Think: extra "cushion" of cortisol** - Moon face - Buffalo hump, trunk obesity - Osteoporosis - Risk for infection - Prone to FVO & CHF (concerned w/ breathing) - Bruises/petechiae - UP x 4, DOWN - Hypernatremia - Hyperglycemia - HTN - Increased blood volume - Hypokalemia - ↓K+ (opposite Na) ## Addison's Disease - Pituitary gland does not produce enough cortisol (hydrocortisone) - **Think: need to "add" cortisol** - Bronze-skin pigmentation - Fatigue - Dehydration - Weakness - DOWN x 4, UP - Hyponatremia - Hypoglycemia - Hypotension - Decreased blood volume - Hyperkalemia - Tx: high sodium diet, administer cortisone & fluids - **If untreated can lead to addisonian crisis** # Thyroid Imbalances ## Hypothyroidism - Deficiency of thyroid hormone - Intolerance to cold (low temp) - Bradycardia - Extreme fatigue/apathy (lack of interest) - Hair loss/brittle nails - Dry skin - Weight gain/puffy face (myxedema) - Heavy menstrual period - Decreased appetite - Tx: synthroid (take in AM on empty stomach) - Myxedema coma = severe hypothyroidism ## Hyperthyroidism = Grave's Disease - Too much thyroid hormone - **Think Michael Jackson in thriller!!** - Skinny - Nervous/agitation - Sweating - Bulging eyes (exophthalmos) - Insomnia - Heat intolerance (high temp) - HTN - Increased appetite - Amenorrhea (scanty menstrual period) - Tx: methimazole (#1 drug - cannot be used in 1st tri of pregnancy, only 2nd & 3rd), PTU (propylthiouracil) - Thyroid storm (thyrotoxic crisis) = severe hyperthyroidism → EMERGENCY # Parathyroid Imbalances ## Hypoparathyroidism - Decreased parathyroid hormone - Hypocalcemia (THINK CATS) - Chvostek's sign - Arrhythmias - Trousseau's Sign/Tetany - Seizures/spasms ## Hyperparathyroidism - Too much parathyroid hormone - Hypercalcemia - Depressed DTR's - Muscle weakness/fatigue - Abdominal pain/distenstion - Dysrhythmias # Diabetes ## Diabetes Insipidus - Too little ADH = excreting large amts of dilute urine - Polydipsia - Dehydration - Low specific gravity (< 1.010) - Hypernatremia - Tachycardia - Hypotension - Can go into hypovolemic shock - Causes: trauma, irradiation of pituitary gland, CNS infections (TB, meningitis) - Tx: Vasopressin, desmopressin acetate (DDAVP) ## SIADH - Too much ADH = too much fluid - Fluid retention - Concentrated urine - High specific gravity (>1.030) - Dilutional hyponatremia - Tachycardia - HTN - Weight gain - Causes: head injury, infection, TCA's, nicotine - Tx: Fluid restriction, diuretics, stadol (inhibits ADH) - LUNG CANCER PT'S MOST AT RISK!!! # Diabetes Mellitus - Type 1 = pancreas can't make insulin, Type 2 = insulin resistance/impaired secretion - **3 P's** - Polyuria (excessive urination) - Polydipsia (excessive thirst) - Polyphagia (excessive hunger) - Hyperglycemia - Slow wound healing - Parasthesias - **Insulin Complications** - Dawn phenomenon: reduced sensitivity to insulin/surge of growth hormone at night that causes hyperglycemia before breakfast (5am-8am) - Tx: administer /increase bedtime dose of insulin - Somogyi phenomenon: normal blood glucose @ bedtime, hypoglycemia occurs @3am causing glucagon to be released, hyperglycemia @ 7am - Tx: decrease bedtime insulin dose or increase bedtime snack - **Diabetes Complications** - Retinopathy - Nephropathy ## Hyperphosphatemia - 3 - Tx: calcitonin (decreases Ca), low calcium high phosphorous diet, parathyroidectomy - Bronchospasms & dysphagia can occur -- keep trach kit at bedside - Hypotension - Tx: calcium gluconate (increases Ca), high calcium low phosphorous diet # Foot Care - Inspect feet daily - Wash feet daily but avoid foot soaks - Apply lotion to feet but DO NOT APPLY BTWN TOES - Do not cross legs - Buy correct shoe size NOT sizes bigger - Buy shoes in afternoon when feet are larger - Have each foot measured every time you buy new shoes - Buy leather shoes NOT vinyl # Parenteral Nutrition (TPN) - Central line (NCLEX will say triple lumen, or tunneled) - Subclavian vein - Basilic vein - Cephalic vein - PICC - High concentration of glucose may need to add regular insulin to TPN - Do not abruptly discontinue the solution → gradually decrease the infusion rate to prevent hypoglycemia - Measure glucose levels q4 - **Risks:** - Pneumothorax & air embolism → improper catheter placement/air enters catheter - Hyperglycemia - Hypervolemia - Hypoglycemia when abruptly discontinued - Infection - Return cloudy/dark solutions back to pharmacy - Must be administered within 24 hours of time prepared # IV Fluid Solutions ## Hypotonic Solutions - More dilute than body fluids - Cause water → INTO cells - 0.45% NaCl - 0.225% NaCl - 0.33% NaCl ## Isotonic Solutions - Equal concentration as body fluids - 0.9% NaCl - D5W - D5W in 0.225% NaCl - Lactated Ringers ## Hypertonic Solutions - More concentrated than body fluids - Water OUT of cells → into extracellular fluid - 3% NaCl - 5% NaCl - D10W - D5W in 0.9% NaCl - D5W in 0.45% NaCl - D5LR (D5 in lactated ringers) # IV Gauges - Smaller gauge = larger diameter lumen - 14-19 gauge - Rapid emergency fluid administration - 20-21 gauge - Blood products - Anesthetics - 22-25 gauge - Peripheral fat emulsion (lipids) - Standard IV fluids - **IV insertion sites to AVOID:** - Same side as mastectomy - Same side as AV fistula/shunt - Skin area that is infected - Edematous extremity - Weak extremity - Insert the IV on the dorsal non-dominant side - The tourniquet should be 3-4 inches above the insertion site # Blood Products - **General Precautions:** - Only 0.9% NaCl can be infusing w/ blood - Blood expires at midnight on day marked on bag - **MUST** be administered within 30 mins of getting it from blood bank - If not used w/in this time must be returned to blood bank - **Assess v/s before, after the 1st 15 mins, then q hr until transfusion is complete** - **Jehovah's Witness cannot receive blood** - **Start infusion @ slow rate** - If there is going to be a reaction it will be w/in 1st 15 mins or 50ml # Transfusion Reactions - **Hemolytic** - Lower back discomfort flank, tachy, HOTN - Rapid thready pulse - Hypotension - **Allergic** - Wheezing, flush, edema - Urticaria - Facial flushing - Epiglottal edema - **Febrile/pyrogenic** - Fever, chills, Sweating - Facial flushing - Fever - **Bacterial** - Septicemia # Restraints - If a reaction occurs STOP THE TRANSFUSION & REMOVE THE TUBING - Change the tubing & keep 0.9% NaCl running - Physical restraints → assess skin q30 mins and remove q2 hrs - restraints: assess skin q30min need Dr. order remove q2hrs # Isolation Precautions ## Airborne - Me = Measles - Chicken = Chicken pox (Varicella) - Hez = Herpes Zoster (ONLY IF DISSEMINATED) - TB = Tuberculosis - **Think Me Chicken Hez TB** - Private negative pressure room w/ doors closed - 6-12 air exchanges per hr - N95 mask - If client needs to leave room place a mask on them - **Think Spiderman** ## Droplet - Sepsis - Scarlet fever - Streptococcal pharyngitis - Parovirus B19 - Pneumonia - Pertussis - Influenza - Diptheria - Epiglottitis - Rubella - Mumps - Meningitis - Meningeal pneumonia - Adenovirus - Private room or cohort (patients with the same organism) - Wear a surgical mask w/in 3 ft of the client - If the client needs to leave the room place a mask on them - **Think MRS. WEE** - - Multi-drug resistant organism (MRSA), VRSA = CONTACT & AIRBORNE ## Contact - RSV - Skin infections (**Think VCHIPS**) - Wound infections - Enteric infections (C.diff, rotavirus) - Eye infections (Conjunctivitis) - Varicella (chicken pox) - needs airborne too! - Cutaneous diphtheria - Herpes simplex, Hemophilia A (ONLY if pt is in diapers or incontinent) Herpes Zoster (ONLY IF LOCALIZED) - Impetigo - Pediculosis - Scabies - **Hep. A/E ** - Private room or cohort client - masks - facle shield # Procedures & Positioning ## Burns - Elevate ## Mastectomy - Face & head → elevate HOB - Extremities → elevate - Semi-fowlers - Affected arm elevated on pillow - Turning back OR unaffected side - 1 month post-op → NORMAL to be CRYING and DIFFICULTY COPING ## Hemorroidectomy - Lateral (side-lying) - Pre-op: supine w/ arms raised above head - Post-op: Right lateral (side-lying) - Small pillow under puncture site (apply pressure) - Referred shoulder pain is EXPECTED ## Liver Biopsy - Abdomen rigid & distended hemorrhage - Insertion: high-fowlers 90° ## NG Tube - Sims position (forward side-lying) w/ knees flexed - Sitting position leaning forward or ortho - Client's arms over pillows or table ortho something ## Rectal enema/irrigation - Semi-fowlers ## COPD - Semi-fowlers ## Laryngectomy - Semi-fowlers ## Thyroidectomy - SF b/c upper resp ## Bronchoscopy - Semi-fowlers ## Paracentesis - Removes fluid from the peritoneal cavity - ascites in the stomach - EMPTY BLADDER ## Thoracentesis - Removes fluid from the thoracic cavity - lungs - EMPTY BLADDER ## Below the Knee Amputation - OR sitting upright w/ feet supported - Immediately after obtain BP - Sitting @ edge of bed leaning over table w/ feet supported - OR lying in bed on unaffected side HOB elevated 45 degrees - Shave area around needle insertion - 1st 24 hrs foot of bed elevated - Prone 20-30mins BID (stretches muscles prevents hip contracture) ## Above the Knee Amputation - 1st 24 hrs elevate on pillow - Prone 20-30mins BID ## Cardiac Catheterization - EMPTY BLADDER - Check allergy to shellfish!!! & NPO 6-8 hrs & HOLD METFORMIN!!!! - Pt may feel palpitations/fluttery/warm feeling or need to cough w/ dye injection - Affected extremity kept straight sumne after - ML 150ML hr x4kg 25 Iry 24 hrs 33:2:15 ML 2m² 1000mg 15kg 2.4 o sing licg 0 1.6 3 15 # Positioning For Other Conditions ## Pulses then pain! - Flat or HOB elevated no more than 30 degrees - Bed rest 4-6 hrs - Immediately after assess B/L puises THEN ask about pain ## Heart Failure/Pulmonary Edema - Upright w/ legs dangling over side of bed (decreases venous return & lung congestion) - Elevate feet at rest but NOT ABOVE LEVEL OF HEART (swelling prevents arterial blood flow but extreme elevation does too) ## Peripheral Arterial Disease - Leg elevation when in bed ## DVT - Leg elevation above heart level, prolonged sitting/standing - Trendelenburg test → use to assess varicose vein pt's ## Varicose Veins - don't elevate ## Cataract Surgery - Semi-fowlers - Back or non-operative side - Immediate post-op → face down ## Retinal Detachment - Dependent position (ex: if left retina = lay on left side) ## Autonomic Dysreflexia - High-fowlers (→ oxygenation) - Hemorrhagic → HOB elevated 30 degrees - Ischemic flat ## Stroke - hom? HOB 130° ## Craniotomy - NOT on affected side - HOB elevated 30-45 degrees, head midline ## Increased ICP - isch? Plut - Semi-fowler's or high-fowlers bed - Head midline ## Lumbar Puncture - During: Lateral (side-lying) - Post-op: supine 4-12 hrs - hold BB if tur ## Total Hip Replacement - AVOIAD ADDUCTION - Side-lying is permitted as long as abduction pillow is in place - Abduction laying supine (pillow btwn legs) - Trochanter rolls prevent external rotation of the legs when the client is supine - Trapeze bar client uses upper extremities to raise trunk ## Post-Gastrectomy (PREVENTING DUMPING SYNDROME) - Chew food well/eat in reclining position - Lie down for 30mins after eating - Restrict fluids during meals (drink btwn meals) - DECREASE carbs & fiber, INCREASE protein & fat, 6 small meals a day curbs fiber - ↑protein/fat - Intestinal tube used to decompress the bowel or remove accumulated intestinal secretions (used for paralytic ileus) - Inserted through nose to small intestine - Lie on right side - EMPTY BLADDER ## Miller-Abbott or Cantor tube - FULL BLADDER ## Amniocentesis - Lie on right side - EMPTY BLADDER ## Ultrasound - FULL BLADDER ## Intravenous Pyelogram (IVP) - X-ray of urinary tract → evaluates kidney function - cleanimal by # MRI - Use bowel prep night before so kidneys/bladder wont be obscured - Stop metformin 48 hrs prior → can cause fatal lactic acidosis - NO DYE OR WIRES USED - Takes 90 mins to complete - Pt must take all metal off - Assess for pacemaker # PKU Test - if(t) give peu,in Amuly # Myelogram - Initial specimen should be obtained as close to discharge as possible but not after 7 days, repeat in 2 weeks - Contrast medium injected into lumbar - Allows x-ray visual of vertebra canal - Identifies tumors, cysts, herniated disks - Post-op: increase fluids to excrete dye, lie flat, monitor v/s & neuro - Preop: bronchodilators withheld, cannot smoke 4 hrs before # Pulmonary Function Test (PFT) - Side lying OR w/ arms raise up on pillows over bedside table - Hold breath mid-expiration - Chest x-ray done immediately after to check for pneumothorax - Sterile dressing applied # Lung Biopsy - AVOID HIGH PROTEIN DIET BEFORE TEST # 24 hr Creatinine Clearance Test - Can drink as much fluid as they want before/during test - Save all urine during 24 hrs & keep in fridge - Avoid strenuous activity (increases Creatinine excretion) - not Huid restricted - ANY PROCEDURE W/ IODINE DYE → HOLD METFORMIN 24-48 HRS BEFORE FOR RISK OF FATAL LACTIC ACIDOSIS - After ANY eye surgery you want to move slowly and avoid bending over → do not want to increase ICP or put pressure on ocular suture line # Tube Feedings - DO NOT administer if bowel sounds are absent - DO NOT administer if residual is more than 100ml → reinsert contents after aspirating (otherwise they will become alkaline) - Flush tube w/ 30-50ml NS before and after med administration & feedings - DO NOT allow the feeding bag to be empty/let air into tubing → pt will vomit - If pt vomits stop the feeding and place into side-lying position - Check NG tube placement before every feeding or med administration pH (<4) - Decrease of flow of gastric secretions & pt nauseas → aspirate contents to verify placement THEN irrigate w/ NS once placement is confirmed by pH - Wait 30mins before reconnecting the feeding after meds (protein affects absorption) - Continuous tube feeding → rinse bag & change formula q4 # Endotracheal Tubes - Used to maintain a patent airway w/ mechanical ventilation - Tracheostomy → used when the client needs an artificial airway for more than 10-14 days 10-14 days - ❖THE CUFF - Inflates and creates a seal preventing aspiration & ensuring set tidal volume - NO air or secretions pass through (pt is unable to speak when cuffed) - Orotracheal & nasotracheal tubes: - Placement is confirmed by x-ray - Auscultate both sides of chest - If breath sounds & chest wall movement are absent on left side, the tube might be in the right main stem bronchus - Auscultate over stomach (to r/o esophageal intubation) - If in the stomach louder breath sounds heard over stomach than chest & abdominal distention - Oral tube → move to opposite side of the mouth daily to prevent pressure & necrosis - Monitor cuff pressures every 8 hrs → SHOULD NOT EXCEED 20mmhg - Suction regulation pressure → when tubing is occluded should = 120-140mmhg - Suctioning → insert catheter until resistance is met, twist & rotate & apply suction while removing catheter not > 10sec. # Chest Tubes - Used to remove accumulations of air & fluid from pleural space (lungs) - Sterile dressing @ insertion site - Keep BELOW the chest & tubes free of kinks - A DO NOT milk the tubing - Keep a clamp (used if system needs to be changed) & dressing @ bedside - DO NOT CLAMP unless HCP says so - IF DRAINAGE SYSTEM COLLAPSES/BREAKS → insert chest tube into a bottle of sterile water & replace the system - When removing a chest tube → client takes a big deep breath & holds it (tube is then removed), dry sterile dressing or petroleum gauze dressing is applied - ❖DRAINAGE CONTROL CHAMBER - Located where the chest tube from the client connects to the system - Drainage from the tube drains into & collects into calibrated columns in the chamber - CALL HCP → more than 70-100ml/hr, bright red drainage, sudden drainage increase - ❖WATER-SEAL CHAMBER - Tip of the tube is underwater → allows fluid/air to drain from pleural space and prevents fluid/air from entering pleural space - Water moves UP as client INHALES - Water moves DOWN as client EXHALES - WATER NOT FLUCTUATING = check length of tube for kinks, suction not working, lung reexpanded - EXCESSIVE BUBBLING = AIR LEAK - INTERMITTENT BUBBLING = PNEUMOTHORAX ## Suction Control Chamber - Provides suction, controlling negative pressure to chest - Filled w/ water (amt depends on level of suction needed) - GENTLE BUBBLING (NOT VIGOROUS) = NORMAL!!! = INDICATES THERE IS SUCTION - If it is a dry suction system there is no bubbling and you control the amt of suction w/ a dial on the wall # Cranial Nerves | Number | Name | Sensory/Motor/Both | What it tests | |---|---|---|---| | I | Olfactory | Sensory | Smell | | II | Optic | Sensory | Vision | | III | Oculomotor | Motor | Pupil constriction, eye movement | | IV | Trochlear | Motor | Downward & inward eye movement | | V | Trigeminal | Both | Mastication muscles → clenching jaw -- Corneal reflex → touch cornea w/ cotton -- Equal B/L sensation when cheeks, eyelids, forehead, chin is touched | | VI | Abducens | Motor | Lateral eye movement | | VII | Facial | Both | Taste test (salty & sweet), smile/frown/show teeth, puff out cheeks | | VIII | Auditory/Acoustic/Vestibulocochlear | Sensory | Hearing tests (weber & rinne), observe balance & watch for swaying when eyes are closed (Romberg test) | | IX | Glossopharyngeal | Both | Tested together → swallowing ability, gag reflex, taste test (bitter & sour) | | X | Vagus | Both | Controls neck & shoulder muscles -- Push chin against nurses hand (sternocleidomastoid muscle) -- Shrug shoulders against resistance (trapezius muscle) | | XI | Spinal Accessory | Motor | Controls tongue movement -- Observe tongue for asymmetry -- Press tongue against tongue depressor -- Move tongue rapidly from side to side & in and out | | XII | Hypoglossal | Motor | | # Erikson's Stages of Psychosocial Development | Stage | Age | Crisis | Successful Task | Toys & Play | |---|---|---|---|---| | Infancy | Birth-18mo | Trust vs Mistrust | Develops trust - Attached to mother - Hold infant often - Encourage parents to be in room while hospitalized - Meet food/hygiene needs | SOLITARY PLAY - Rattles - Teething toys - Blocks - Nesting-toys (cups that fit into each other) | | Early Childhood | 18mo-3y | Autonomy vs Shame and Doubt | Gaining basic self-control - Allow self-feeding opportunities - Encourage child to remove/put on own clothes - Allow for choice | PARALLEL PLAY - Push-pull toys - Filling & emptying containers - Finger paint - Large crayons - Mimic their same gender parent | | Late Childhood | 3-6y | Initiative vs Guilt | Initiates own activities w/ a purpose - Allow play w/ medical equipment - Accept choices & expression of feelings | ASSOCIATIVE & COOPERATIVE PLAY - Imaginary play - Tricycles - Dress up & role playing - Puzzles - Basic collections (ex: barbies) | | School Age | 6-12y | Industry vs Inferiority | Developing social, physical & learning skills - Encourage child to continue schoolwork while hospitalized & bring favorite pastimes to hospital | COMPETITIVE & COOPERATIVE PLAY - Bicycles, skateboards - Sports | | Adolescence | 12-20y | Identity vs Role Confusion | Developing identity - learning who they are - Health history w/out parents in room - Introduce to other hospitalized teens w/ same condition | | | Early Adulthood| 20-35y | Intimacy vs Isolation | Establishing intimate bonds of relationship & friendship & commitment | | | Middle Adulthood | 35-65y | Generativity vs Stagnation | Fulfilling life goals involving family, friends & career | | | Later Adulthood | 65y – death | Integrity vs Despair | Looking back on ones life and accepting meaning - Sense of fulfillment and integrity | | # Infant Growth and Development | Age | Milestones | |---|---| | 2 - 3 months | 2 months → Posterior fontanel closes (6-8 weeks) - Smiles, cries, turns head side to side, follows objects, hold head erect on examination table - Colic can appear - Recurrent daily episodes of unexplained inconsolable crying - Baby is red, diaphoretic, quivering, crying - Unknown cause & goes away on its own - Biggest concern is shaken baby syndrome!!! (parents get frustrated) - Tell the parents to put the baby safe in the crib & walk away OR use motion (ex: swing) | | 4 - 5 months | - Grasps - Switches objects from hands - Rolls over for first time - Begins to show memory & aware of unfamiliar surroundings - Introduce solid foods (4-6 months) - Iron fortified rice cereal - Fruits then vegetables then meats - Introduce something new every 4 – 7 days to identify allergies | | 6 - 7 months | - Sits with support - Creeps (pushing around on stomach) - Waves bye-bye - First teeth appear - Teething begins @ 3-4 months (give them cold things for discomfort) | # Toddler Development | Age | Milestones | |---|---| | 8 - 9 months | - Sits unsupported - Crawls - Stands while holding on or begins to stand w/o help - think STANDS STRAIGHT AT EIGHT - Finger foods (8-10months pincer grasp) → think 10 fingers - FOODS TO GIVE: cheerios, puffs - CHOKING RISK FOODS: nuts, seeds, raisins, popcorn, grapes, hot dog pieces, apple skin (peel apples) - Says "mama" and "dada" → 8 LETTERS - Changes from prone to sitting **think BELLY TO BUTT** (phrase has 10 letters)| | 10 - 11 months | - Stands securely - Walks holding onto furniture - Walks w/ one hand held - Can take a few steps w/out falling - Can drink from a cup - **think 12 AND UP DRINK FROM A CUP** | | 12 - 13 months | - Test for lead poisoning (give them milik if they have lead poisoning) - NO COWS MILK BEFORE 12 MONTHS OLD (ONLY BREASTMILK) - 12 months start whole milk - Can speak 3-5 words and comprehends the word “no” → 8 LETTERS + 3-5 WORDS= 12-13 | | 14 - 15 months | - Walks alone - Crawl upstairs/climbing | | 18 months | -