NursingPlex · 2026 Edition

Full Ultimate Nursing Bundle

Every high-yield NCLEX topic in one complete, printable guide.

99 topics9 subjects

nursingplex.com

Contents

1Cardiac & EKG12
2Respiratory8
3Maternity8
4Pediatrics7
5Pharmacology16
6Fundamentals11
7Med-Surg · Renal24
8Mental Health9
9Dosage Calculation4

© 2026 NursingPlex. All rights reserved. The Full Ultimate Nursing Bundle — every topic, summary, table, rhythm strip and memory hook in it — is the original work of NursingPlex and is protected by copyright law. No part of this guide may be copied, reproduced, redistributed, resold, or shared with third parties — in whole or in part, in any format — without prior written permission from NursingPlex. Violations, including reselling this guide, will be reported and pursued to the fullest extent of the law.

Reading an EKG Strip

The paper, the waves, and a 5-step routine to use on every strip

Cardiac & EKG

The paper

Standard speed 25 mm/sec.
1 small box = 0.04 sec (1 mm). 1 large box = 0.20 sec (5 small boxes).
5 large boxes = 1 second; 30 large boxes = 6 seconds.
Height: 10 small boxes = 1 mV (amplitude, not time).

Heart rate: three methods

6-second method (any rhythm, best for irregular): count QRS complexes in 6 sec × 10.
300 method (regular only): 300 ÷ number of large boxes between two R waves.
1500 method (regular, most precise): 1500 ÷ number of small boxes between R waves.

300 sequence: 1 box = 300, 2 = 150, 3 = 100, 4 = 75, 5 = 60, 6 = 50.

Normal sinus rhythm (lead II)

P wave = atrial depolarization. Upright and rounded in lead II; one before every QRS.

QRS = ventricular depolarization. (Atrial repolarization is hidden inside it.)

T wave = ventricular repolarization. Peaked T → think hyperkalemia; flat T or U wave → hypokalemia.

Normal intervals (adult)

Measure	Normal	What it means
Heart rate	60–100/min	<60 brady, >100 tachy
PR interval	0.12–0.20 s	3–5 small boxes; AV conduction time
QRS	0.06–0.10 s	≥0.12 s = wide (ventricular origin or bundle branch block)
QTc	<0.45 s (men) <0.46 s (women)	QTc >0.50 s = high risk of torsades

5-step routine

Look at the patient first. Pulse, BP, LOC, symptoms. Treat the patient, not the monitor.
Rate: atrial and ventricular.
Rhythm: regular or irregular? (march out the R–R intervals).
P waves: present? upright? one per QRS? any P without a QRS?
PR and QRS: measure. Constant or changing PR? Narrow or wide QRS?

5-lead placement

White: right arm (below right clavicle). Black: left arm.
Green: right lower chest/abdomen. Red: left lower chest/abdomen.
Brown (chest): V1, 4th intercostal space, right sternal border (or as ordered).

Memory hook "White on the right, smoke (black) over fire (red), snow (white) over grass (green)."
Artifact vs. real VF? Check the patient. A talking patient with a "VF" strip has loose leads or is moving.

Sinus Rhythms

The impulse starts in the SA node: every P wave is followed by a QRS

Cardiac & EKG

Sinus bradycardia

Treat only if symptomatic

Rate<60/min

RhythmRegular

P waveNormal, 1 per QRS

PR0.12–0.20 s

QRS<0.12 s

Causes: athletes and sleep (normal), vagal stimulation (vomiting, suctioning, bearing down), hypothermia, hypothyroidism, ↑ICP (Cushing's triad), inferior MI, hyperkalemia, drugs (beta blockers, diltiazem/verapamil, digoxin, amiodarone, opioids).
Symptomatic if: hypotension, dizziness/syncope, altered mental status, chest pain, signs of shock or acute HF.

Treatment (symptomatic):

Atropine 1 mg IV, repeat every 3–5 min, max 3 mg. Updated (old dose 0.5 mg)
If atropine fails: transcutaneous pacing, or dopamine 5–20 mcg/kg/min or epinephrine 2–10 mcg/min infusion.
Treat the cause; hold rate-lowering drugs and notify the prescriber.

Sinus tachycardia

A response, not a disease: find the cause

Rate>100/min (usually ≤150 at rest)

RhythmRegular

P waveNormal, 1 per QRS

PR0.12–0.20 s

QRS<0.12 s

Causes: fever, pain, anxiety, hypovolemia or bleeding, hypoxia, anemia, sepsis, hyperthyroidism, PE, heart failure, stimulants (caffeine, nicotine, cocaine), drugs (albuterol, epinephrine, atropine), alcohol or drug withdrawal.

Treatment: treat the cause: fluids or blood for volume loss, analgesia, antipyretics, oxygen if hypoxic. Do not try to "convert" sinus tachycardia with adenosine or cardioversion.
Watch for: ↓ filling time → ↓ cardiac output, angina in CAD.

Sinus arrhythmia

Rate varies with breathing (speeds up on inspiration, slows on expiration). Normal in children and young adults. No treatment.

Sinus arrest / pause

SA node fails to fire: a flat gap with no P, QRS or T. Report long pauses (e.g., >3 sec) and symptoms; may need a pacemaker (sick sinus syndrome).

Priority Sudden bradycardia after suctioning or during a bowel movement = vagal response: stop the stimulus, assess the patient.

Cushing's triad (↑ICP): bradycardia + widening pulse pressure (rising systolic BP) + irregular respirations. This is a late sign: notify immediately.

Atrial Rhythms and SVT

Narrow-complex tachycardias that start above the ventricles

Cardiac & EKG

Atrial fibrillation (A-fib)

Irregularly irregular, no P waves

RateAtrial 350–600 (chaotic); ventricular varies (RVR >100)

RhythmIrregularly irregular

P waveNone: wavy fibrillatory baseline

PRNone (cannot measure)

QRSUsually <0.12 s

Main danger: stroke. Blood pools in the left atrial appendage → clot → embolic stroke. Loss of "atrial kick" also ↓ cardiac output.
Causes: HTN, CAD, HF, valve disease, age, hyperthyroidism, alcohol, sleep apnea, obesity, after heart surgery.
Assess: apical pulse for a full minute (pulse deficit), palpitations, fatigue, dyspnea, dizziness.

Treatment:

Unstable → synchronized cardioversion.
Rate control: beta blocker (metoprolol), diltiazem (not in HFrEF), digoxin.
Rhythm control: cardioversion, amiodarone and others, catheter ablation.
A-fib ≥48 h or unknown: anticoagulate ≥3 weeks or TEE before elective cardioversion, and ≥4 weeks after.
Anticoagulation by CHA₂DS₂-VASc score: DOACs preferred over warfarin, except mechanical valve or moderate–severe mitral stenosis (warfarin). Updated

Atrial flutter

Sawtooth waves

Atrial rate250–350

VentricularDepends on ratio: 2:1 ≈150, 4:1 ≈75

RhythmUsually regular

P waves replaced by sawtooth flutter waves (best in II, III, aVF); PR not measurable; QRS narrow. A regular narrow rhythm at exactly ~150 → think flutter with 2:1 block.
Treatment: same rules as A-fib (rate control, cardioversion, anticoagulation). Catheter ablation is often curative.

SVT

Sudden start, sudden stop

Rate150–250

RhythmRegular

P / QRSP hidden; QRS narrow

Stable: vagal maneuvers (modified Valsalva), then adenosine 6 mg rapid IV push into a proximal IV followed immediately by a 20 mL saline flush; if needed 12 mg. Warn: brief chest pressure, flushing, and a few seconds of asystole on the monitor are expected. Run a strip.
Unstable: synchronized cardioversion.

CHA₂DS₂-VASc (stroke risk in A-fib)

C CHF	1	H Hypertension	1
A₂ Age ≥75	2	D Diabetes	1
S₂ Stroke/TIA/thromboembolism	2	V Vascular disease (MI, PAD)	1
A Age 65–74	1	Sc Sex category (female)	1

Anticoagulation recommended at ≥2 (men) or ≥3 (women); considered at 1 (men) or 2 (women).

Priority Unstable = hypotension, acutely altered mental status, signs of shock, ischemic chest pain, or acute heart failure. Any unstable tachycardia with a pulse → synchronized cardioversion.

Adenosine and diltiazem are avoided in A-fib with a wide, very fast, irregular QRS (possible WPW): they can trigger VF.

Ventricular Rhythms

Wide QRS (≥0.12 s): the impulse starts in the ventricles

Cardiac & EKG

Premature ventricular contractions (PVCs)

An early, wide, bizarre beat

Look for: an early beat with a wide, bizarre QRS and no P wave before it; the T wave points the opposite way to the QRS; usually followed by a full compensatory pause.
Patterns: bigeminy (every 2nd beat), trigeminy (every 3rd), couplet (2 in a row), 3 or more in a row = VT.
Causes: hypokalemia, hypomagnesemia, hypoxia, MI/ischemia, HF, caffeine, nicotine, alcohol, stimulants, digoxin toxicity.

Nursing:

Assess the patient and pulse (a PVC may not produce a pulse: pulse deficit).
Check K⁺ and Mg²⁺, oxygenation, and meds; treat the cause.
Report: increasing frequency, couplets, runs, multifocal PVCs, or R-on-T (PVC landing on the T wave can trigger VT/VF).
Occasional PVCs in a healthy person are often benign.

Ventricular tachycardia (VT)

Check for a pulse: it decides the treatment

Rate100–250 (usually >150)

RhythmRegular (monomorphic)

P waveNot seen

PRNone

QRSWide (≥0.12 s), bizarre

Patient status	Treatment
Pulseless	Treat as VF: CPR + defibrillation, epinephrine, amiodarone or lidocaine.
Pulse, unstable	Synchronized cardioversion (sedate if possible).
Pulse, stable	12-lead EKG, expert consult; antiarrhythmic such as amiodarone 150 mg IV over 10 min (or procainamide); correct K⁺/Mg²⁺.

Causes: MI/ischemia, cardiomyopathy, HF, low K⁺ or Mg²⁺, hypoxia, acidosis, drug toxicity (digoxin, QT-prolonging drugs).

Torsades de pointes

Polymorphic VT + long QT

QRS "twists" around the baseline, getting taller then shorter.
Causes: QT-prolonging drugs (haloperidol, ondansetron, methadone, macrolides, fluoroquinolones, citalopram, amiodarone, sotalol), low Mg²⁺, low K⁺, low Ca²⁺.
Treatment: magnesium sulfate 1–2 g IV; stop QT-prolonging drugs; correct K⁺. Pulseless or unstable → defibrillate (unsynchronized: polymorphic rhythms can't be synced).

Updated: what changed Vasopressin is no longer in the adult cardiac arrest algorithm (removed 2015). Epinephrine is the vasopressor used.

Lidocaine is an accepted alternative to amiodarone for shock-refractory VF/pulseless VT.

Older guides that list "vasopressin 40 units" for VT/VF are out of date.

Lethal Rhythms: VF, Asystole and PEA

No pulse = start CPR. Then ask one question: shockable or not?

Cardiac & EKG

Ventricular fibrillation (VF)

Shockable

Looks like: chaotic, irregular waves; no identifiable P, QRS or T; rate cannot be counted. Coarse or fine.
Patient: unresponsive, no pulse, not breathing or only gasping. No cardiac output.

Treatment:

Start CPR; defibrillate as soon as possible (biphasic 120–200 J per device; monophasic 360 J).
Resume CPR immediately after each shock for 2 min.
Epinephrine 1 mg IV/IO every 3–5 min (after 2nd shock).
Amiodarone 300 mg IV/IO, then 150 mg; or lidocaine 1–1.5 mg/kg, then 0.5–0.75 mg/kg.

Asystole

Not shockable

Confirm it: check the patient, the leads and connections, turn up the gain, check a second lead (fine VF can look flat).
Treatment: high-quality CPR + epinephrine 1 mg as soon as possible, then every 3–5 min; look for reversible causes. Never defibrillate asystole.

Pulseless electrical activity (PEA)

The monitor shows an organized rhythm (it may even look normal) but there is no palpable pulse.

Treatment: same as asystole: CPR, epinephrine as soon as possible, find and fix the cause (Hs and Ts). Not shockable.

Memory hook"Shock the chaos, push epi for the flat." VF and pulseless VT get shocks; asystole and PEA get CPR + epinephrine + a search for the cause.

Reversible causes: the Hs and Ts

Hs
Hypovolemia	Fluids, blood
Hypoxia	Airway, oxygen, ventilation
Hydrogen ion (acidosis)	Ventilation; bicarbonate in selected cases
Hypo-/hyperkalemia	Correct K⁺ (calcium for high K⁺)
Hypothermia	Rewarm

Ts
Tension pneumothorax	Needle decompression
Tamponade (cardiac)	Pericardiocentesis
Toxins	Antidote (e.g., naloxone)
Thrombosis, pulmonary (PE)	Consider fibrinolytic
Thrombosis, coronary (MI)	Cath lab after ROSC

Priority During CPR, an end-tidal CO₂ <10 mmHg suggests poor-quality compressions. A sudden rise to 35–45 mmHg suggests return of spontaneous circulation (ROSC).

Heart Blocks

A delay or block between the atria (P) and the ventricles (QRS)

Cardiac & EKG

1st-degree AV block

Usually benign

PR >0.20 s and constant; every P is followed by a QRS. Rate and rhythm usually normal.
Causes: beta blockers, CCBs, digoxin, amiodarone, high vagal tone, inferior MI, hyperkalemia, aging.
Care: usually no treatment; review meds; watch for progression.

2nd-degree type I (Wenckebach)

Mobitz I

PR gets progressively longer until one P is not followed by a QRS (dropped beat), then the cycle repeats. Ventricular rhythm irregular; QRS usually narrow.
Care: usually transient; treat only if symptomatic (atropine); review meds.

2nd-degree type II

Mobitz II: dangerous

PR constant, then a QRS is suddenly dropped without warning. QRS often wide (block below the AV node).
Danger: can progress suddenly to 3rd-degree block.
Care: transcutaneous pacing pads on, prepare for a pacemaker; atropine is unlikely to work.

3rd-degree (complete) block

Emergency

P waves and QRS complexes are completely independent: Ps "march through" at their own regular rate; PR varies with no pattern; atrial rate > ventricular rate (escape rhythm 20–60).
Care: transcutaneous pacing, dopamine or epinephrine infusion as a bridge, then a permanent pacemaker.

Compare at a glance

Block	PR interval	Dropped QRS?
1st degree	Long, constant	No
2nd, type I	Gets longer each beat	Yes, after the longest PR
2nd, type II	Constant	Yes, without warning
3rd degree	No relationship	P and QRS independent

Memory hook "If the R is far from P, then you have a first degree.
Longer, longer, longer, drop: then you have a Wenckebach.
If some Ps don't get through, then you have a Mobitz II.
If Ps and Qs don't agree, then you have a third degree."

Pacemaker nursing

Know the set rate; a pacer spike should be followed by a P (atrial) or a wide QRS (ventricular): capture.
Failure to capture: spike with no QRS after it. Failure to sense: spikes in the wrong place, including on T waves.
Transcutaneous pacing is painful: give analgesia/sedation as ordered; confirm a pulse matches the paced rate.

After a permanent pacer: limit raising the arm on the insertion side above the shoulder as instructed (often for a few weeks); watch the site for bleeding, hematoma, infection.
Carry the device ID card; tell providers before MRI (many devices are MRI-conditional only); keep phones and magnets ~6 in (15 cm) from the device.

CPR and ACLS Essentials

Based on the 2025 AHA Guidelines for CPR and Emergency Cardiovascular Care

Cardiac & EKG

Adult high-quality CPR

Check responsiveness; shout for help; activate emergency response; get the AED.
Check breathing and carotid pulse together for ≤10 sec.
Compress the lower half of the sternum: 100–120/min, depth at least 2 in (5 cm) but not more than 2.4 in (6 cm), full chest recoil.
30:2 compressions to breaths without an advanced airway.
With an advanced airway: continuous compressions + 1 breath every 6 sec.
Minimize pauses (<10 sec); switch compressors every 2 min; avoid over-ventilation.

AED steps

Turn it on and follow the prompts.
Bare, dry chest; pads on (remove medication patches; place pads away from an implanted device).
Stand clear while it analyzes.
If shock advised: everyone clear, shock.
Resume CPR immediately, starting with compressions. Don't stop to check a pulse after the shock.

Suspected opioid overdose: give naloxone, but CPR comes first if there's no pulse.

Cardiac arrest: the two pathways

Shockable: VF / pulseless VT

Shock → CPR 2 min (get IV/IO access).
Shock → CPR 2 min + epinephrine 1 mg every 3–5 min; consider advanced airway.
Shock → CPR 2 min + amiodarone 300 mg (2nd dose 150 mg) or lidocaine; treat reversible causes.

Non-shockable: asystole / PEA

CPR 2 min + epinephrine 1 mg as soon as possible, then every 3–5 min.
Rhythm check every 2 min. If it becomes shockable, switch pathways.
Search for and treat the Hs and Ts.

Defibrillation vs. cardioversion

	Defibrillation	Synchronized cardioversion
For	Pulseless VF/VT; polymorphic VT	Unstable tachycardia with a pulse (A-fib, flutter, SVT, monomorphic VT)
Sync	Off	On: shock timed to the R wave so it doesn't land on the T wave
Patient	Unconscious	Often awake: sedate if possible; consent if time allows

If the patient goes into VF during cardioversion: turn sync off and defibrillate.

Key ACLS drugs

Epinephrine	1 mg IV/IO every 3–5 min in arrest
Amiodarone	Arrest: 300 mg, then 150 mg. Stable VT with pulse: 150 mg over 10 min
Lidocaine	1–1.5 mg/kg, then 0.5–0.75 mg/kg
Adenosine	6 mg rapid push + flush, then 12 mg
Atropine	1 mg every 3–5 min, max 3 mg (bradycardia)
Magnesium	1–2 g IV (torsades)

After ROSC

Secure airway; SpO₂ 90–98%; PaCO₂ 35–45 (avoid hyperventilation).
Avoid hypotension: MAP ≥65 mmHg.
12-lead EKG: STEMI → emergency cath.
Not following commands: deliberate temperature control 32–37.5°C (89.6–99.5°F) for ≥36 h; prevent fever. Updated
Check glucose; ongoing neuro assessment.

Safety during shocks "I'm clear, you're clear, everyone's clear." Oxygen source away from the chest; nobody touching the patient or bed. Remove medication patches and wipe the skin. Place pads at least 1 in (2.5 cm) away from a pacemaker or ICD generator.

Hypertension

2025 AHA/ACC High Blood Pressure Guideline

Cardiac & EKG

Blood pressure categories (adults)

Category	Systolic		Diastolic
Normal	<120	and	<80
Elevated	120–129	and	<80
Stage 1 hypertension	130–139	or	80–89
Stage 2 hypertension	≥140	or	≥90
Severe hypertension	>180	and/or	>120

If the two numbers fall in different categories, use the higher category. Diagnose from the average of ≥2 readings on ≥2 occasions (home or ambulatory readings confirm).

Measure it right

No caffeine, smoking or exercise for 30 min; empty bladder.
Sit 5 min, back supported, feet flat, legs uncrossed.
Arm supported at heart level; bare arm.
Correct cuff size: bladder encircles ~80% of the arm. Too small → falsely high; too large → falsely low.
No talking during the reading.

When to start medication

Everyone with elevated BP or hypertension: lifestyle changes.
Stage 2: start medication; often 2 drugs, preferably in a single combined pill.
Stage 1: start medication if the person has heart disease, diabetes, CKD or a PREVENT 10-year cardiovascular risk ≥7.5%; otherwise lifestyle for 3–6 months, then medication if BP stays ≥130/80.
Target: <130/80 for most adults (lower systolic, toward 120, if tolerated).

First-line drug classes

Thiazide-type diuretic (chlorthalidone, HCTZ) · ACE inhibitor or ARB (never both together) · long-acting dihydropyridine CCB (amlodipine).

Pregnancy: avoid ACE inhibitors and ARBs; use labetalol, extended-release nifedipine, or methyldopa.

Lifestyle (each lowers systolic BP)

Weight loss	~1 mmHg per kg lost
DASH eating pattern	Fruit, vegetables, whole grains, low-fat dairy
Sodium	Ideally <1,500 mg/day, or cut by ≥1,000 mg/day
Potassium	Potassium-rich foods (unless CKD or K⁺-raising drugs)
Activity	≥150 min/week moderate (or 75 min vigorous) aerobic + resistance training ≥2 days/week
Alcohol	Ideally none; at most 1/day (women), 2/day (men)
Smoking	Stop

Severe hypertension: urgency vs. emergency

Without new organ damage: resume or adjust oral meds and arrange close follow-up. Lower gradually.

Hypertensive emergency = severe BP plus acute target-organ damage: brain (headache, confusion, seizure, stroke), eyes (vision change), heart (chest pain, pulmonary edema), aorta (dissection), kidneys (↓ urine output, ↑ creatinine).

ICU; arterial line; IV titratable drug (nicardipine, clevidipine, labetalol, esmolol).
Lower BP by no more than 25% in the first hour, then to ~160/100–110 over the next 2–6 h, then toward normal over 24–48 h.
Exceptions: aortic dissection (rapidly to systolic <120), severe preeclampsia, acute stroke (special targets).

PriorityDropping BP too fast in a hypertensive emergency can cause stroke, MI or kidney injury from under-perfusion. Titrate, don't crash it.

Orthostatic hypotension

Drop of ≥20 mmHg systolic or ≥10 mmHg diastolic within 3 min of standing. Teach: rise slowly, dangle legs before standing, hydrate, report dizziness. Common with diuretics, alpha blockers, and in older adults.

Heart Failure

2022 AHA/ACC/HFSA Heart Failure Guideline

Cardiac & EKG

Types by ejection fraction (EF)

HFrEF (reduced)	EF ≤40%
HFmrEF (mildly reduced)	EF 41–49%
HFpEF (preserved)	EF ≥50%
HFimpEF (improved)	Was ≤40%, now >40%

BNP >100 pg/mL or NT-proBNP >300 pg/mL supports HF; levels fall as HF improves. Normal EF is ~50–70%.

Left-sided vs. right-sided

Left: backs up into the Lungs

Dyspnea, orthopnea, PND
Crackles, cough, pink frothy sputum
S3 gallop, tachycardia
Fatigue, confusion, ↓ urine output

Right: backs up into the Rest of the body

JVD
Dependent edema, weight gain
Hepatomegaly, ascites
Anorexia, nausea

The most common cause of right-sided HF is left-sided HF.

HFrEF: the four core drug classes Updated

Class	Examples	Nursing points
ARNI (preferred) or ACEi/ARB	sacubitril/valsartan; lisinopril; losartan	Hypotension, ↑K⁺, renal function. 36-hour gap when switching from an ACE inhibitor to an ARNI (angioedema risk).
Evidence-based beta blocker	carvedilol, metoprolol succinate, bisoprolol	Start low, go slow; may feel more tired at first. Hold for symptomatic bradycardia or hypotension.
Mineralocorticoid receptor antagonist (MRA)	spironolactone, eplerenone	Check K⁺ and creatinine; avoid potassium supplements and salt substitutes.
SGLT2 inhibitor	dapagliflozin, empagliflozin	Benefit with or without diabetes. Genital infections, volume depletion, rare euglycemic DKA; usually held ~3 days before surgery.

Loop diuretics (furosemide) relieve congestion and symptoms but don't prolong life. For HFpEF, SGLT2 inhibitors and diuretics are the mainstay.

Acute decompensated HF

High Fowler's; oxygen to keep SpO₂ ≥90% (non-invasive ventilation if needed).
IV loop diuretic; monitor urine output, K⁺, Mg²⁺, creatinine, BP.
Vasodilators (nitroglycerin) if BP allows.
Strict I&O, daily weight, lung sounds.
Avoid: NSAIDs, diltiazem/verapamil (in HFrEF), thiazolidinediones (pioglitazone).

Teaching for home

Weigh daily: same time, same scale, after voiding, before breakfast, similar clothing.
Report a gain of >1 kg (2–3 lb) in a day or 2 kg (5 lb) in a week, or worse breathlessness, swelling, or needing more pillows.
Limit sodium (commonly <2–3 g/day); fluid limits only if ordered.
Take meds even when feeling well; check BP/pulse as taught.
Stay active (cardiac rehab); flu, COVID and pneumococcal vaccines.

Digoxin

Check the apical pulse for 1 full minute first; hold and notify if <60/min (adults) or as ordered. Therapeutic level 0.5–2.0 ng/mL (0.5–0.9 is the target in HF). Toxicity: anorexia, nausea, vomiting, visual changes (yellow-green halos), bradycardia, dysrhythmias. Hypokalemia increases toxicity. Antidote: digoxin immune fab.

Memory hook Left = Lungs. Right = Rest of the body.

Classes I–IV (NYHA) describe symptoms and can go up and down. Stages A–D (ACC/AHA) describe progression and only move forward.

Acute Coronary Syndrome

Unstable angina, NSTEMI and STEMI (2025 ACC/AHA ACS Guideline)

Cardiac & EKG

Unstable angina

Chest pain at rest, new, or worsening. Troponin normal. No ST elevation. Emergency: can progress to MI.

NSTEMI

Troponin elevated. No persistent ST elevation (may show ST depression or T-wave inversion).

STEMI

ST elevation in 2 contiguous leads + rising troponin. Complete blockage: time is muscle.

Recognize it

Pressure, squeezing or heaviness in the chest; may spread to arm, jaw, neck, back; sweating, nausea, dyspnea.
Women, older adults and people with diabetes often have atypical symptoms: fatigue, dyspnea, nausea, epigastric discomfort.
12-lead EKG within 10 minutes of arrival.
High-sensitivity troponin at arrival and repeated (rises within hours; stays up 1–2 weeks).

Which leads, which artery

Inferior	II, III, aVF	Right coronary
Anterior/septal	V1–V4	Left anterior descending
Lateral	I, aVL, V5–V6	Circumflex

Inferior MI: get right-sided leads. A right ventricular infarct is preload-dependent: avoid nitrates and diuretics; give IV fluids for hypotension.

Immediate treatment

Aspirin 162–325 mg chewed (non-enteric-coated), unless true allergy or active bleeding.
Nitroglycerin 0.4 mg SL every 5 min, up to 3 doses, if systolic BP ≥90. Not with sildenafil/vardenafil in the last 24 h or tadalafil in 48 h, or RV infarct.
Oxygen only if SpO₂ <90%. Updated
Morphine only for pain not relieved by nitrates. Updated

Second antiplatelet (P2Y12: ticagrelor, prasugrel, clopidogrel) + anticoagulant (heparin).
High-intensity statin; beta blocker within 24 h if no HF, shock or bradycardia.
STEMI → PCI: first medical contact-to-device ≤90 min (≤120 min if transferring). If PCI can't happen in time: fibrinolytic within 30 min of arrival.

After PCI (cardiac cath)

Check site, distal pulses, color, temperature and sensation as per protocol (e.g., every 15 min at first).
Radial: compression band, release per protocol; no BP or blood draws on that arm.
Femoral: keep leg straight and HOB low as ordered. Back or flank pain + hypotension → retroperitoneal bleed: report now.
Contrast: hydrate; watch urine output and creatinine.

Discharge teaching

Dual antiplatelet therapy (usually 12 months): never stop without the cardiologist; bleeding precautions.
Chest pain at home: stop, sit, take 1 SL nitroglycerin. If not better or worse after 5 min, call emergency services; may repeat every 5 min, max 3.
Keep nitroglycerin in its original dark glass bottle; carry it always.
Cardiac rehab; stop smoking; heart-healthy diet; sex is usually safe once able to climb 2 flights of stairs, as cleared.

Updated: "MONA" is no longer the rule Older guides teach Morphine, Oxygen, Nitrates, Aspirin for every MI. Routine oxygen in patients with normal saturation gives no benefit, and morphine can delay the effect of oral antiplatelet drugs. Give aspirin and nitrates; oxygen only if SpO₂ <90%; morphine only for refractory pain.

Coronary Artery Disease and Cholesterol

Angina types, lipid targets and lipid-lowering drugs

Cardiac & EKG

Stable angina

Predictable chest pain with exertion or stress; relieved by rest or nitroglycerin within minutes.

Unstable angina

New, at rest, or worsening; not relieved by rest. Treat as ACS: emergency.

Variant (Prinzmetal)

Coronary vasospasm, often at rest/night. Treated with CCBs and nitrates; avoid triggers (smoking, cocaine).

Lipid values (adults)

Lab	Desirable
Total cholesterol	<200 mg/dL
LDL ("bad")	<100 mg/dL (lower targets, e.g. <70 or <55, in people with heart disease)
HDL ("good")	Men ≥40 mg/dL; women ≥50 mg/dL
Triglycerides	<150 mg/dL

Some guides reverse the HDL numbers by sex. It's women ≥50, men ≥40.

Risk factors

Can't change

Age (men ≥45, women ≥55)
Family history of early CAD
Sex, genetics

Can change

Smoking, high BP, high LDL
Diabetes, obesity, inactivity
Unhealthy diet, heavy alcohol use
Chronic kidney disease

Lipid-lowering drugs

Drug	Key points
Statins (atorvastatin, rosuvastatin, simvastatin)	First-line; lower LDL most. Report muscle pain, weakness, dark urine (myopathy, rhabdomyolysis: check CK). Baseline liver tests. Simvastatin and lovastatin are taken in the evening; atorvastatin and rosuvastatin any time. Avoid large amounts of grapefruit with simvastatin, lovastatin, atorvastatin. Usually stopped in pregnancy.
Ezetimibe	Blocks cholesterol absorption; added to a statin.
PCSK9 inhibitors (evolocumab, alirocumab), inclisiran	Injections for very high risk or statin intolerance; large LDL reductions.
Bempedoic acid	Oral option for statin intolerance; can raise uric acid (gout).
Bile acid sequestrants (cholestyramine)	Constipation; bind other drugs: give other meds 1 h before or 4–6 h after; may ↓ fat-soluble vitamins.

Tests

Stress test: avoid caffeine 12–24 h before; some meds (e.g. beta blockers) may be held as ordered.
Cardiac cath: check allergies, kidney function, anticoagulants; metformin may be held around contrast if kidney function is poor.
Lipid panel: fasting not always required; follow the lab's instructions.

Memory hook HDL = Happy/Healthy: you want it High.
LDL = Lousy: you want it Low.
Nystatin is an antifungal, not a statin.

Stroke: Time-Critical Care

Ischemic vs. hemorrhagic, thrombolytics, and nursing priorities

Cardiac & EKG

Recognize: BE FAST

Balance	Sudden loss of balance or coordination
Eyes	Sudden vision loss or double vision
Face	Facial droop
Arm	Arm (or leg) weakness
Speech	Slurred or confused speech
Time	Note last known well; call emergency services

First steps

ABCs; check blood glucose (hypoglycemia mimics stroke).
Non-contrast CT immediately: rules out bleeding before any clot-busting drug.
NIH Stroke Scale; time of last known well.
NPO until a swallow screen is passed (aspiration risk), including oral meds.

Ischemic stroke: reperfusion

IV thrombolytic within 4.5 hours of last known well (the standard window ends at 4.5 h; it does not start at 3 h). 2026 AHA/ASA: selected patients up to 9 h, or wake-up stroke, if advanced imaging shows salvageable brain. Updated

Alteplase 0.9 mg/kg (max 90 mg): 10% as a bolus over 1 min, rest over 60 min; or
Tenecteplase 0.25 mg/kg (max 25 mg) single IV bolus. Updated

Streptokinase and reteplase are not used for stroke.

Mechanical thrombectomy for large-vessel occlusion: up to 24 h in selected patients.

BP before thrombolytic: <185/110. Keep ≤180/105 for 24 h after.

Exclusions (examples): any bleeding on CT, active internal bleeding, recent major surgery, head trauma or stroke, BP that can't be lowered below 185/110, low platelets or anticoagulation (check labs/history).

After: neuro checks and VS every 15 min × 2 h, every 30 min × 6 h, hourly × 16 h; no antithrombotics for 24 h; avoid invasive procedures. New headache, worse neuro status, nausea/vomiting, or sudden BP rise → stop the infusion, call, urgent CT.

Hemorrhagic stroke

Usually sudden severe headache ("worst of my life"), vomiting, ↓ LOC.
Lower systolic BP (commonly to ~140); reverse anticoagulants.
ICP care: HOB 30°, head midline, avoid straining, coughing and hip flexion; seizure precautions.
No thrombolytics, antiplatelets or anticoagulants.

Right vs. left hemisphere

Right brain (left-side weakness)

Impulsive, poor judgment, safety risk
Left-sided neglect; spatial problems
Denies deficits

Left brain (right-side weakness)

Aphasia (speech, language)
Slow, cautious, anxious
Aware of deficits; may be depressed

Rehab nursing

Homonymous hemianopia: place food and items in the intact visual field; teach head-turning to scan the blind side.
Dysphagia: upright 90°, chin tuck, thickened liquids as ordered by IDDSI level.
Approach and speak from the unaffected side early on; encourage use of the affected side over time.

Priority TIA (symptoms resolve, no infarct on imaging) is a warning: high stroke risk in the next days. Needs same-day evaluation.

Arterial Blood Gases

Interpret any ABG in four steps

Respiratory

Normal values

pH	7.35–7.45	<7.35 acidosis · >7.45 alkalosis
PaCO₂	35–45 mmHg	Lungs. CO₂ acts as an acid
HCO₃⁻	22–26 mEq/L	Kidneys. Bicarbonate is a base
PaO₂	80–100 mmHg	<80 = hypoxemia
SaO₂	95–100%	Hemoglobin saturation

Four steps

pH: acidosis or alkalosis? (If normal, which side of 7.40 is it on?)
PaCO₂: does it match the pH problem? If yes → respiratory.
HCO₃⁻: does it match the pH problem? If yes → metabolic.
Compensation: is the other value moving the opposite way?

Uncompensated	pH abnormal; other value normal
Partially compensated	pH abnormal; both values abnormal
Fully compensated	pH normal (7.35–7.45); both values abnormal

Memory hook: ROME Respiratory Opposite: in respiratory problems, pH and PaCO₂ move in opposite directions (pH ↓, CO₂ ↑). Metabolic Equal: in metabolic problems, pH and HCO₃⁻ move in the same direction (pH ↓, HCO₃⁻ ↓).

Causes and clues

Imbalance	Common causes	Clues
Respiratory acidosis	Hypoventilation: COPD, opioid/sedative overdose, neuromuscular weakness, airway obstruction, severe asthma (tiring)	Drowsy, confused, headache; slow or shallow breathing
Respiratory alkalosis	Hyperventilation: anxiety, pain, fever, early sepsis, early PE, high altitude, ventilator rate too high	Light-headed, tingling around mouth and fingers
Metabolic acidosis	DKA, lactic acidosis (shock, sepsis), kidney failure, severe diarrhea, salicylate toxicity	Kussmaul breathing (deep, rapid), hyperkalemia
Metabolic alkalosis	Vomiting, NG suction, loop/thiazide diuretics, too much antacid or bicarbonate, hypokalemia	Slow shallow breathing, muscle twitching, hypokalemia

Practice (cover the answers)

pH 7.30 · CO₂ 55 · HCO₃ 24	Uncompensated respiratory acidosis
pH 7.48 · CO₂ 30 · HCO₃ 23	Uncompensated respiratory alkalosis
pH 7.28 · CO₂ 30 · HCO₃ 14	Partially compensated metabolic acidosis
pH 7.37 · CO₂ 58 · HCO₃ 32	Fully compensated respiratory acidosis
pH 7.52 · CO₂ 44 · HCO₃ 34	Uncompensated metabolic alkalosis

Oxygen targets

Most acutely ill adults: SpO₂ 92–96%.
At risk of CO₂ retention (COPD, obesity hypoventilation): 88–92%.
Pulse oximeters can over-read in darker skin, and read falsely normal in carbon monoxide poisoning. Check an ABG when it matters.
Anion gap = Na⁺ − (Cl⁻ + HCO₃⁻); normal ~8–12. High gap → DKA, lactate, kidney failure, toxins.

Oxygen Delivery and Airway Care

Devices, safety, and spotting hypoxia early

Respiratory

Oxygen devices

Device	Flow	Approx. FiO₂	Key points
Nasal cannula	1–6 L/min	24–44%	Each L/min adds ~4%. Check ears and nares for pressure injury.
Simple face mask	5–10 L/min	35–55%	Minimum 5 L/min to flush out exhaled CO₂.
Non-rebreather mask	10–15 L/min	60–80%+	Reservoir bag must stay inflated; one-way valves. Short-term, high need.
Venturi mask	Per adaptor	24–60%	Most precise FiO₂: useful in COPD.
High-flow nasal cannula	up to 60 L/min	21–100%	Heated, humidified; reduces work of breathing.
CPAP / BiPAP	Pressure-set	Set	BiPAP for hypercapnic COPD exacerbation; CPAP for sleep apnea and pulmonary edema. Patient must be alert and able to protect the airway.

Signs of hypoxia

Early

Restlessness, anxiety
Tachycardia, tachypnea
Confusion, irritability
Rising BP

Late

Cyanosis
Bradycardia, hypotension
Dysrhythmias
Lethargy, coma

A newly restless or confused patient: check oxygenation before giving a sedative.

Oxygen safety

No smoking, candles, or open flames; post "oxygen in use".
Secure cylinders upright in a stand or cart.
Water-based lubricant only on lips and nares (no petroleum jelly).
Avoid prolonged high FiO₂ (oxygen toxicity); give the lowest FiO₂ that meets the target.

Incentive spirometer

Sit upright; exhale normally.
Seal lips around the mouthpiece.
Inhale slowly and deeply to raise the piston.
Hold the breath 3–5 seconds, then exhale.
Repeat 10 times every hour while awake; cough afterwards (splint incisions).

Suctioning (adult)

Suction only when needed (secretions heard or seen, ↓ SpO₂, ↑ airway pressure).
Pre-oxygenate; sterile technique for artificial airways.
Wall pressure ~100–150 mmHg; apply suction only while withdrawing.
Each pass ≤10–15 seconds; limit passes; reoxygenate between.
Stop for bradycardia, dysrhythmia or desaturation.

Tracheostomy

Keep a spare trach (same size and one smaller) and obturator at the bedside.
Humidify; trach care and dressing changes per policy; clean inner cannula.
Accidental dislodgement (fresh trach <7 days): call for help, oxygenate by face/stoma; don't blindly reinsert a fresh trach unless trained.

Positioning Dyspnea: high Fowler's or tripod position. One-sided lung disease: "good lung down" (better perfusion to the healthy lung), except in lung abscess or hemorrhage. ARDS: prone positioning as ordered.

COPD

GOLD 2025: chronic airflow limitation that is not fully reversible

Respiratory

Two patterns

Emphysema

Alveolar walls destroyed; air trapping
Barrel chest, thin, pursed-lip breathing
Hyperresonance; diminished breath sounds

Chronic bronchitis

Productive cough ≥3 months for 2 years in a row
Frequent infections, hypoxemia, edema
Rhonchi, wheezes; possible cor pulmonale

Diagnosis: spirometry after bronchodilator: FEV₁/FVC <0.70. Main cause: smoking (also biomass smoke from cooking fuels, occupational dusts, alpha-1 antitrypsin deficiency).

Oxygen in COPD Updated

Target SpO₂ 88–92% in people at risk of CO₂ retention.

Why: too much oxygen worsens ventilation–perfusion mismatch and reduces hemoglobin's CO₂ carrying (Haldane effect), so CO₂ rises. The old "hypoxic drive" explanation is outdated.

Never withhold oxygen from a hypoxic patient. Titrate to the target and watch for drowsiness (rising CO₂).

Long-term home O₂ if resting PaO₂ ≤55 mmHg or SpO₂ ≤88%.

Medications

Drug group	Examples	Role
LAMA + LABA	tiotropium, umeclidinium + salmeterol, formoterol, vilanterol	Mainstay maintenance for most patients
Inhaled corticosteroid (added)	fluticasone, budesonide	Only with long-acting bronchodilators, if exacerbations and blood eosinophils ≥300 (or ≥100 with frequent exacerbations). ↑ pneumonia risk.
SABA / SAMA	albuterol; ipratropium	Rescue for symptoms
Add-ons	Exacerbations: roflumilast; azithromycin (selected); dupilumab (eosinophils ≥300) or mepolizumab (≥150) despite triple therapy. Persistent symptoms: ensifentrine (nebulized)	Newer options New

Acute exacerbation

SABA ± ipratropium (nebulizer or MDI with spacer).
Systemic corticosteroid (e.g., prednisone 40 mg daily for 5 days).
Antibiotics if sputum becomes purulent or ventilation is needed.
Controlled oxygen 88–92%; ABG.
BiPAP for hypercapnic respiratory acidosis (pH ≤7.35, PaCO₂ >45).

Nursing and teaching

Smoking cessation: the single most effective intervention.
Pursed-lip breathing (in through nose, out slowly through pursed lips, exhale twice as long); huff coughing.
Upright or tripod position; pace activities; pulmonary rehab.
High-calorie, high-protein small frequent meals; rest before eating.
Fluids ~2–3 L/day to thin secretions unless restricted (e.g., HF).
Vaccines: influenza yearly, COVID-19, pneumococcal, RSV, Tdap, zoster.

Priority A COPD patient who becomes drowsy or confused on oxygen may be retaining CO₂: check the ABG, titrate oxygen down to the target range, and prepare for BiPAP. Cor pulmonale (right heart failure from lung disease): JVD, edema, hepatomegaly.

Asthma

GINA 2025: chronic airway inflammation with variable, reversible obstruction

Respiratory

Recognize

Wheeze, cough (often at night or early morning), chest tightness, dyspnea.
Triggers: allergens, smoke, cold air, exercise, viral infections, aspirin/NSAIDs in some, beta blockers, stress.

Danger signs of a severe attack

Can't speak in full sentences; accessory muscle use; SpO₂ <90%.
"Silent chest": little air movement, so wheezing disappears.
Drowsy or confused; normal or rising PaCO₂ = tiring out.

Peak flow zones

Green ≥80%	of personal best: continue usual plan
Yellow 50–79%	use reliever; follow action plan; contact provider
Red <50%	use reliever now; seek emergency care

Measure: stand, full breath, seal lips, blow hard and fast; best of 3.

Long-term treatment (adults and adolescents ≥12) Updated

Preferred (GINA Track 1): the reliever is low-dose ICS-formoterol (budesonide-formoterol) taken as needed.

Mild asthma: as-needed ICS-formoterol only.
Moderate to severe: maintenance-and-reliever therapy (MART): the same ICS-formoterol inhaler every day and as needed.

SABA alone (albuterol only) is no longer recommended: it treats symptoms but not inflammation and increases the risk of severe attacks and death.

If albuterol is the reliever (Track 2), take an inhaled corticosteroid too, every time or daily.

Add-ons: LAMA, montelukast (boxed warning: mood and behavior changes), biologics (omalizumab, mepolizumab, benralizumab, dupilumab, tezepelumab).

Acute exacerbation

SABA (albuterol) repeated, e.g., every 20 min in the first hour; add ipratropium if severe.
Systemic corticosteroid early (oral prednisone or IV).
Oxygen to SpO₂ 93–95% adults (94–98% children).
IV magnesium sulfate for severe attacks not responding.
No sedatives. Prepare for intubation if tiring.

Inhaler technique

MDI: shake; breathe out; seal lips (spacer preferred); press once and breathe in slowly over 3–5 s; hold ~10 s; wait 30–60 s between puffs.
Dry powder inhaler: don't shake; don't breathe into it; breathe in fast and deep.
Rinse mouth and spit after a steroid inhaler (prevents thrush).
Two inhalers: bronchodilator first, then the steroid.

Priority LABA (salmeterol, formoterol) is never used alone in asthma: always combined with an inhaled corticosteroid. A patient whose wheezing "stops" while still struggling to breathe is getting worse, not better.

Pneumonia and Tuberculosis

Infection, precautions, and prevention

Respiratory

CAP

Community-acquired: starts outside hospital or within 48 h of admission.

HAP

Hospital-acquired: starts ≥48 h after admission.

VAP

Ventilator-associated: starts ≥48 h after intubation.

"HCAP" (healthcare-associated pneumonia) was dropped from US guidelines in 2019. Updated

Assessment

Fever, chills, productive cough, pleuritic chest pain, dyspnea, tachypnea.
Crackles; bronchial breath sounds, dullness and ↑ tactile fremitus over consolidation.
Older adults: may present with confusion, falls, no fever.
Chest X-ray; sputum and blood cultures before antibiotics (don't delay antibiotics in sepsis).
CURB-65 severity: Confusion, Urea (BUN >19 mg/dL), RR ≥30, BP <90 systolic or ≤60 diastolic, age ≥65.

Care and prevention

Antibiotics on time; oxygen to target; fluids unless restricted.
HOB ≥30°; turn, cough, deep breathe; incentive spirometer; early mobility.
Aspiration precautions: swallow screen, sit at 90° to eat, chin tuck, oral care.
Vaccines: pneumococcal (PCV20 or PCV21, or PCV15 + PPSV23) for all adults ≥50 and younger adults with risk conditions; yearly influenza; COVID-19; RSV for older or high-risk adults. Updated

Tuberculosis (TB)

S&S: cough >3 weeks, hemoptysis, night sweats, weight loss, low-grade afternoon fever, fatigue.
Screening: TST (skin test) or IGRA blood test. Positive = infection, not proof of active disease. TST read in 48–72 h; ≥5, ≥10 or ≥15 mm is positive depending on risk group.
Active disease: chest X-ray + 3 sputum samples for AFB smear, NAAT and culture (at least one early morning). Culture confirms.

Airborne precautions: negative-pressure room, fit-tested N95; patient wears a surgical mask when outside the room.
Standard treatment: RIPE (rifampin, isoniazid, pyrazinamide, ethambutol) for 2 months, then rifampin + isoniazid for 4 months (6 months total). A 4-month regimen is an option for some.
Directly observed therapy (DOT) improves adherence.
Usually non-infectious after ~2 weeks of effective treatment, clinical improvement, and negative sputum smears (per policy).

Memory hook: TB drugs (details in Pharmacology) Rifampin turns body fluids Red-orange and weakens birth control · Isoniazid causes neuropathy: give vitamin B6 · Pyrazinamide raises uric acid · Ethambutol affects the Eyes. All except ethambutol can harm the liver.

Mechanical Ventilation

Lung-protective settings, alarms, and preventing VAP

Respiratory

Settings to know Updated

Tidal volume 6–8 mL/kg of predicted (ideal) body weight, calculated from height. ~6 mL/kg in ARDS. Old fixed volumes like "500–800 mL" over-stretch the lungs.
Plateau pressure ≤30 cmH₂O.
PEEP keeps alveoli open; can ↓ BP (less venous return).
Lowest FiO₂ that meets the SpO₂ target.
Modes: assist-control (full support), SIMV, pressure support (weaning).

Endotracheal tube

Confirm placement: waveform capnography (most reliable) + bilateral breath sounds and chest rise + chest X-ray.
Note the cm mark at the teeth or lips each shift.
Cuff pressure 20–30 cmH₂O.
Secure the tube; restraints only if needed and ordered.

Ventilator alarms

Alarm	Common causes	Action
High pressure	Secretions, coughing, biting the tube, kinked tubing, water in tubing, bronchospasm, pneumothorax	Suction, bite block, straighten or drain tubing, assess breath sounds, notify
Low pressure / low volume	Disconnection (most common), cuff leak, tube displaced, circuit leak	Check connections from patient to vent; check cuff and tube position
Apnea	Patient not triggering breaths (over-sedation)	Assess; check mode and sedation

If you can't find and fix the cause right away: disconnect and ventilate with a bag-valve device on 100% O₂, and call for help.

VAP prevention bundle

HOB 30–45° unless contraindicated.
Daily sedation interruption + spontaneous breathing trial.
Oral care with toothbrushing. Updated Routine chlorhexidine mouthwash is no longer recommended (SHEA 2022).
Subglottic suction tubes for longer ventilation; drain tubing condensate away from the patient.
Early mobility; DVT and stress-ulcer prophylaxis as indicated.

Complications

VAP; barotrauma or pneumothorax (sudden high pressures, absent breath sounds, ↓ SpO₂).
Hypotension from positive pressure.
Stress ulcers, DVT, muscle weakness, pressure injury at lips.
Delirium: screen daily.

After extubation

High Fowler's, oxygen, cough and deep breathe; watch for stridor (airway edema: report now); swallow assessment before eating.

Memory hook: sudden deterioration on the ventilator = DOPE Displaced tube · Obstructed tube (secretions, kink) · Pneumothorax · Equipment failure.

Chest Tubes and Pneumothorax

How the drainage system works and what to do when something goes wrong

Respiratory

Collection chamber

Holds drainage. Mark the level and time each shift (or as ordered).

Report >100 mL/hour (or per order) or bright red drainage.

Water seal

One-way valve (~2 cm water). Tidaling (rise and fall with breathing) is normal.

Continuous bubbling = air leak. Intermittent bubbling on exhale/cough can be expected with a pneumothorax.

Suction control

Wet: gentle continuous bubbling (vigorous bubbling only evaporates water). Dry: dial set (often −20 cmH₂O) with the indicator showing.

Do

Keep the unit upright and below chest level.
Keep tubing free of kinks and dependent loops.
Check dressing, insertion site, crepitus (subcutaneous air), breath sounds, SpO₂.
Keep at bedside: sterile water and an occlusive dressing (and clamps if policy).
Encourage coughing, deep breathing, incentive spirometry, pain control.

Don't

Don't clamp routinely (risk of tension pneumothorax): only briefly to find a leak, to change the unit, or if ordered.
Don't strip or milk the tubing routinely.
Don't lift the unit above the chest.

Tidaling stopped?

Either the lung has re-expanded (good: confirm with X-ray), or the tube is kinked, clotted or blocked (check).

Emergencies

Problem	Action
Tubing disconnected from the unit	Put the tube end 2–4 cm under sterile water, then reconnect or replace the unit.
Tube pulled out of the chest	Cover the site with a sterile occlusive dressing (taped on 3 sides if there's an air leak, per policy); stay with the patient; notify; watch for tension pneumothorax.
Unit knocked over	Set it upright; check the water seal level; notify if drainage mixed between chambers.

Pneumothorax types

Spontaneous: tall thin young adults, smokers, lung disease.
Open (sucking chest wound): cover with a vented or 3-sided occlusive dressing.
Tension: air trapped with each breath → shift of the mediastinum. Tracheal deviation away from the affected side, absent breath sounds, JVD, hypotension, severe distress. Emergency: needle decompression, then chest tube.
Hemothorax: blood in the pleural space.

Memory hook Air rises, fluid falls. A tube for air sits higher (apex); a tube for fluid sits lower (base). Many tubes for both are placed at the 4th–5th intercostal space, mid-axillary line.

Removal: patient holds breath or performs Valsalva as instructed; occlusive dressing; chest X-ray after.

Pulmonary Embolism and DVT

Venous thromboembolism: prevent it, recognize it, act fast

Respiratory

Virchow's triad

Stasis: immobility, long travel, HF, A-fib.
Vessel injury: surgery (especially hip/knee), trauma, central lines.
Hypercoagulability: cancer, pregnancy and postpartum, estrogen (pills, HRT), smoking, obesity, inherited clotting disorders, previous VTE.

DVT signs

One-sided calf or thigh swelling, pain, warmth, redness.
Diagnose with compression ultrasound.
Homans' sign is unreliable: don't rely on it.
Never massage a leg with a suspected clot.

Pulmonary embolism

Signs

Sudden dyspnea and tachypnea (most common).
Pleuritic chest pain, tachycardia, anxiety or sense of doom.
Cough, hemoptysis, hypoxemia, low-grade fever.
Massive PE: hypotension, syncope, JVD, cardiac arrest (PEA).

Tests

CT pulmonary angiography; V/Q scan if contrast can't be used.
D-dimer: a normal result helps rule PE out when risk is low; a high result is non-specific.
ABG: hypoxemia with respiratory alkalosis early. EKG: often sinus tachycardia.

Nursing actions if PE is suspected

Stay with the patient; call for help (rapid response).
Raise the head of bed; give oxygen.
Vital signs, SpO₂, IV access; prepare for tests.

Treatment

Anticoagulation: heparin or LMWH, or a DOAC (apixaban, rivaroxaban) from the start.
Thrombolytic for massive PE with hypotension (if no contraindication).
Catheter-directed treatment or surgical embolectomy in selected cases.
IVC filter only if anticoagulation isn't possible.

Prevention

Early ambulation; ankle pumps and leg exercises.
Sequential compression devices (not on a leg with a known clot).
Pharmacologic prophylaxis: enoxaparin or SC heparin as ordered.
Hydration; avoid crossing legs, pillows under knees, tight garments.

Priority A post-op or immobile patient with sudden shortness of breath and chest pain has a PE until proven otherwise. Act first, then document.

Prenatal Care and Nutrition

Dating, visits, labs, supplements and warning signs

Maternity

Dating the pregnancy

Naegele's rule: first day of last menstrual period + 7 days − 3 months + 1 year.
Early ultrasound (crown–rump length) is the most accurate dating.
Fundal height: 12 wk at the symphysis; ~20 wk at the umbilicus; from 20–36 wk, height in cm ≈ weeks (±2 cm).
Preterm <37 0/7 wk · early term 37 0/7–38 6/7 · full term 39 0/7–40 6/7 · late term 41 0/7–41 6/7 · post-term ≥42 0/7.

GTPAL

Gravida (pregnancies) · Term births · Preterm births · Abortions/miscarriages (<20 wk) · Living children. Twins count as one pregnancy and one birth.

Supplements and diet

Folic acid	400 mcg (0.4 mg) daily, starting ≥1 month before conception; 4 mg after a previous neural tube defect
Iron	27 mg/day (prenatal vitamin); more if anemic
DHA (omega-3)	200–300 mg/day (milligrams, not micrograms) or 2–3 servings of low-mercury fish/week
Calcium	1,000 mg/day (1,300 mg for teens)
Calories	No extra in 1st trimester; ~+340/day 2nd; ~+450/day 3rd

Avoid: alcohol (no safe amount), smoking, unpasteurized dairy and deli meats (Listeria), raw meat and cat litter (toxoplasmosis), high-mercury fish (shark, swordfish, king mackerel, tilefish, bigeye tuna, marlin); caffeine <200 mg/day.

Typical prenatal timeline

When	What
First visit	Blood type, Rh and antibody screen, CBC, rubella and varicella immunity, HIV, syphilis, hepatitis B and C, urine culture, Pap/HPV if due; offer genetic screening
10–14 weeks	Cell-free DNA (from 10 wk) and/or nuchal translucency screening (offered)
15–22 weeks	Maternal serum AFP (neural tube defects); anatomy ultrasound ~18–22 wk
24–28 weeks	Glucose screen for gestational diabetes; CBC; antibody screen if Rh-negative
28 weeks	Rh immune globulin if Rh-negative and unsensitized
27–36 weeks	Tdap every pregnancy (ideally early in this window); RSV vaccine at 32–36 wk during September–January (or infant antibody after birth)
36 0/7–37 6/7 weeks	Group B strep vaginal–rectal culture

Influenza and COVID-19 vaccines can be given in any trimester. Live vaccines (MMR, varicella) are not given in pregnancy. Visit frequency: every 4 weeks to 28 wk, every 2 weeks to 36 wk, then weekly.

Normal changes

Blood volume ↑ 40–50% → physiologic anemia (Hgb <11 g/dL in 1st/3rd trimester or <10.5 in 2nd is anemia).
HR ↑ 10–15/min; BP dips in 2nd trimester.
Supine hypotension: uterus compresses the vena cava → place on her left side (or wedge under right hip).
hCG maintains the corpus luteum (and progesterone) early in pregnancy. It's the hormone pregnancy tests detect. It does not feed the fetus.

Teach: report right away Vaginal bleeding · gush or leak of fluid · severe headache, vision changes, RUQ/epigastric pain, sudden swelling of face or hands · decreased fetal movement · regular contractions before 37 weeks · fever or painful urination · persistent vomiting · thoughts of self-harm.

Hypertensive Disorders of Pregnancy

Gestational hypertension, preeclampsia, eclampsia and HELLP

Maternity

Definitions

Chronic HTN	BP ≥140/90 before pregnancy or before 20 weeks
Gestational HTN	New BP ≥140/90 after 20 weeks, no proteinuria or severe features
Preeclampsia	New BP ≥140/90 after 20 wk (two readings ≥4 h apart) plus proteinuria (≥300 mg/24 h or protein/creatinine ≥0.3) or a severe feature
Eclampsia	New seizure in preeclampsia
HELLP	Hemolysis, Elevated Liver enzymes, Low Platelets

Severe features

BP ≥160 systolic or ≥110 diastolic
Platelets <100,000/µL
Liver enzymes ≥2× normal; severe RUQ or epigastric pain
Creatinine >1.1 mg/dL or doubled
Pulmonary edema
New headache not relieved by medication; visual disturbances

Can start or worsen after birth (up to 6 weeks, mostly in the first week): teach warning signs at discharge.

Prevention: low-dose aspirin Must know

Aspirin 81 mg daily, started at 12–28 weeks (ideally before 16) and continued until delivery, for people at high risk:

High risk (any one): previous preeclampsia, twins/multiples, chronic HTN, diabetes, kidney disease, lupus or antiphospholipid syndrome.
Moderate risk (more than one): first pregnancy, BMI >30, family history, age ≥35, IVF, low income, Black race (reflecting racism-related risk), >10 years since last pregnancy.

Severe-range BP: treat within 30–60 min

If BP stays ≥160 systolic or ≥110 diastolic for 15 min:

Labetalol IV (avoid in asthma, heart block)
Hydralazine IV
Nifedipine immediate-release oral

Goal: lower to ~140–150/90–100, not to normal (protect placental blood flow). Delivery is the cure; betamethasone if birth is likely before 34 weeks.

Magnesium sulfate: prevents seizures (it is not an antihypertensive)

Loading 4–6 g IV over 15–30 min, then 1–2 g/hour by infusion pump on a secondary line.
Usually continued 24 hours after birth.
Therapeutic level ~4–7 mEq/L (4.8–8.4 mg/dL).
Check hourly: deep tendon reflexes, respirations, urine output, LOC, SpO₂, lung sounds. Magnesium is cleared by the kidneys.
Expected: flushing, warmth, drowsiness. It can also slow labor and cause newborn drowsiness and low tone.

Magnesium toxicity Loss of patellar reflexes (first sign) · RR <12 · urine <30 mL/h · SpO₂ falling · slurred speech, extreme weakness · cardiac arrest at very high levels.

Stop the infusion, call the provider, and give the antidote: calcium gluconate 1 g IV (10 mL of 10%) slowly over ~3 min.

Eclamptic seizure

Call for help; stay; note the time.
Turn on her side; protect from injury. Don't restrain; nothing in the mouth.
After: airway, suction, oxygen; magnesium sulfate as ordered.
Assess the fetus (expect bradycardia during the seizure) and watch for abruption.

HELLP

RUQ or epigastric pain, nausea, vomiting, malaise. It can occur with normal-looking BP. Labs: hemolysis (↑ LDH, ↑ bilirubin), ↑ AST/ALT, platelets <100,000. Risks: liver rupture, DIC, abruption. Treatment: stabilize, magnesium, deliver.

Labor and Birth

Stages, cervical change, induction, and labor emergencies

Maternity

Stages of labor

Stage	From → to	Key points
1st: latent phase	Onset → 6 cm	Slower, irregular progress; rest, hydrate, walk
1st: active phase	6 cm → 10 cm	Faster dilation; stronger, regular contractions; transition (8–10 cm): nausea, shaking, urge to push
2nd	10 cm → birth of baby	Pushing; monitor FHR more often
3rd	Birth → delivery of placenta	Usually <30 min. Separation signs: gush of blood, cord lengthens, uterus rises and becomes globular
4th	First 1–2 h after placenta	Recovery: VS and fundus every 15 min in the first hour; highest risk of hemorrhage

Cervix and fetal position

Dilation 0–10 cm; effacement 0–100% (thinning).
Station: −5 to +5; 0 = at the ischial spines (engaged).
Most common position: LOA (left occiput anterior). Posterior (OP) → back labor.
Contraction frequency = start of one to start of the next; duration = start to end of one.
Tachysystole: >5 contractions in 10 min, averaged over 30 min.

True vs. false labor

True	False
Regular, closer together, stronger	Irregular, no pattern
Continues with walking or rest	Eases with rest, fluids, position change
Back pain moving to the front	Felt in front/abdomen
Cervix changes	No cervical change

Rupture of membranes

Check the FHR right away after rupture (cord prolapse risk).
Note fluid COAT: Color (clear normal; green = meconium), Odor (foul = infection), Amount, Time.
Nitrazine paper turns blue (alkaline amniotic fluid); ferning under the microscope.
Rupture >18 h → infection risk: monitor temperature.

Induction and augmentation

Bishop score ≥8 = favorable cervix. Lower → cervical ripening first.
Misoprostol (PGE1) or dinoprostone (PGE2), or a balloon catheter. No misoprostol with a previous cesarean or uterine scar (rupture risk). Start oxytocin ≥4 h after the last misoprostol dose.
Oxytocin (high-alert): infusion pump, piggybacked into the main line at the port closest to the patient. Titrate per protocol. Stop it for tachysystole with an abnormal FHR or a Category III tracing. Watch for water intoxication (headache, confusion, ↓ urine).

Preterm labor (<37 weeks)

Tocolytics delay birth ~48 h to allow steroids and transfer: nifedipine; indomethacin (<32 wk, ≤48 h); terbutaline (short-term only: boxed warning against prolonged or oral use).
Betamethasone 12 mg IM × 2 doses 24 h apart (24 0/7–33 6/7 wk; considered from 22 wk and in selected late-preterm cases) for fetal lung maturity.
Magnesium sulfate before 32 wk for fetal neuroprotection.

Emergencies Cord prolapse: call for help; gloved hand lifts the presenting part off the cord; knee-chest or Trendelenburg; don't push the cord back; keep it moist; emergency cesarean.
Shoulder dystocia: McRoberts (thighs to abdomen) + suprapubic pressure. Never fundal pressure.
Epidural hypotension: side-lying, IV fluid bolus, vasopressor as ordered; check the bladder.

Fetal Heart Rate Monitoring

NICHD definitions, categories and intrauterine resuscitation

Maternity

Baseline and variability

Baseline	110–160 bpm (average over 10 min)
Tachycardia	>160 for ≥10 min: maternal fever or infection, maternal tachycardia, terbutaline, fetal hypoxia, anemia
Bradycardia	<110 for ≥10 min: hypoxia, cord prolapse, maternal hypotension, uterine rupture, beta blockers
Variability	Absent (undetectable) · minimal (≤5) · moderate (6–25) = reassuring · marked (>25)

Minimal variability can be fetal sleep (up to ~40 min), opioids or magnesium, or hypoxia.

Accelerations

A good sign: the fetus is well-oxygenated (not acidotic).

≥32 weeks: rise ≥15 bpm lasting ≥15 sec.
<32 weeks: rise ≥10 bpm lasting ≥10 sec.

Sinusoidal pattern

Smooth, wave-like, no variability: severe fetal anemia (e.g., Rh disease, fetal bleeding). Category III.

Decelerations

Type	Looks like	Cause	Action
Early	Gradual; mirrors the contraction (lowest point at the peak)	Head compression	None: normal
Variable	Abrupt drop and return; V, U or W shape; any timing	Cord compression	Reposition; if recurrent: stop oxytocin, check for prolapse, amnioinfusion if ordered
Late	Gradual; the lowest point comes after the peak of the contraction, and it recovers after the contraction ends	Uteroplacental insufficiency	Intrauterine resuscitation (below); notify
Prolonged	Drop ≥15 bpm lasting 2–10 min	Many (cord, hypotension, tachysystole)	Resuscitation; notify; prepare for birth

Memory hook: VEAL CHOP

Variable	Cord compression
Early	Head compression
Accelerations	OK (oxygenated)
Late	Placental insufficiency

Three categories

Category I (normal): baseline 110–160, moderate variability, no late or variable decels (early decels and accels may be present).
Category II (indeterminate): everything that is not I or III. Evaluate, resuscitate, re-evaluate.
Category III (abnormal): absent variability with recurrent lates, recurrent variables, or bradycardia; or sinusoidal. Prepare for rapid delivery.

Intrauterine resuscitation (late decels, recurrent variables, Category II–III)

Stop oxytocin.
Reposition (left or right lateral, hands-and-knees).
IV fluid bolus; correct maternal hypotension (epidural).
Treat tachysystole (terbutaline if ordered).

Vaginal exam if cord prolapse possible.
Notify the provider; document actions and response.
Prepare for expedited birth if it doesn't resolve.
Oxygen: give for maternal hypoxia. Updated Routine high-flow O₂ by non-rebreather for fetal benefit is not supported by current evidence.

Postpartum Hemorrhage

The leading preventable cause of maternal death worldwide

Maternity

Definition (ACOG)

Cumulative blood loss ≥1,000 mL, or blood loss with signs of hypovolemia, within 24 h of birth, by any route of delivery.

Primary: first 24 h. Secondary: 24 h to 12 weeks.
Measure, don't guess: quantitative blood loss (weigh pads: 1 g ≈ 1 mL).
Vital signs change late in young healthy patients. A shock index (HR ÷ systolic BP) >0.9 is an early warning.

Causes: the 4 Ts

Tone	Uterine atony (most common): overdistended uterus (twins, big baby, polyhydramnios), long labor, oxytocin, infection, magnesium
Trauma	Lacerations, hematoma, uterine inversion or rupture. Bleeding with a firm uterus → think trauma
Tissue	Retained placenta or clots; placenta accreta
Thrombin	Clotting disorders, DIC (abruption, preeclampsia/HELLP, sepsis)

First actions

Fundal massage (support the lower uterus above the pubic bone with the other hand).
Call for help; activate the hemorrhage protocol.
Empty the bladder (a full bladder pushes the uterus up and to the right).
Two large-bore IVs; fluids; oxygen; legs raised.
Labs: CBC, type and crossmatch, coagulation, fibrinogen.
Uterotonics and TXA as ordered; keep counting blood loss.

Tranexamic acid (TXA) Must know

1 g IV over 10 min, as soon as possible and within 3 hours of birth, given alongside uterotonics. A second 1 g dose if bleeding continues after 30 min or restarts within 24 h.

Reduces death from bleeding (WOMAN trial; endorsed by ACOG). Less effective the later it's given.

Uterotonic drugs

Drug	Usual dose	Watch for / avoid
Oxytocin	IV infusion (10–40 units in 500–1,000 mL) or 10 units IM	First-line. Never undiluted IV push (hypotension)
Methylergonovine	0.2 mg IM every 2–4 h	Avoid in hypertension or preeclampsia (vasoconstriction). Refrigerate
Carboprost	250 mcg IM every 15–90 min (max 8 doses)	Avoid in asthma (bronchospasm). Diarrhea, fever. Refrigerate
Misoprostol	600–1,000 mcg oral, sublingual or rectal	Fever, shivering; diarrhea

If bleeding continues

Uterine balloon tamponade, uterine artery embolization, compression sutures, hysterectomy. Massive transfusion protocol (red cells, plasma, platelets, fibrinogen/cryo).

Hematoma

Severe perineal or rectal pain and pressure, swelling, signs of blood loss with little visible bleeding.

Priority A boggy uterus + heavy bleeding → massage first. Uterus firm but bright red bleeding continues → laceration: notify.
Saturating a pad in ≤1 hour, or clots larger than an egg, is excessive bleeding.

Postpartum Care

Assessment, breastfeeding, mastitis and mood

Maternity

Systematic check: BUBBLE-LE

Breasts	Soft, filling, engorged; nipple trauma
Uterus	Firm, midline; height vs. umbilicus
Bladder	Voiding; distension; displaced fundus
Bowel	Bowel sounds, flatus, constipation
Lochia	Color, amount, clots, odor
Episiotomy/incision	REEDA: redness, edema, ecchymosis, discharge, approximation
Legs	Calf pain, swelling (VTE)
Emotions	Bonding, mood, support

Uterus and lochia

Rises to about the umbilicus within 12 h, then descends ~1 cm (1 fingerbreadth) per day; not palpable abdominally by ~2 weeks.
Boggy → massage. Up and to the right → full bladder: help her void.

Rubra	Days 1–3	Dark red, small clots
Serosa	Days 4–10	Pink-brown
Alba	Day 10 to ~6 wk	Yellow-white

Foul odor → infection. Temp up to 100.4°F (38°C) in the first 24 h is often dehydration; above that after 24 h → look for infection.

Breastfeeding

Feed on demand, 8–12 times in 24 h.
Good latch: wide open mouth, lips flanged out, much of the areola in the mouth, audible swallowing, no ongoing pain.
Enough milk: by day 5+, ≥6 wet diapers and 3–4 yellow stools a day; weight regained by 10–14 days.
Engorgement: feed often, cold packs after feeds, supportive bra.

Mastitis (ABM 2022) Updated

Keep feeding normally on demand. It's safe for the baby to feed from the affected breast.
Don't over-pump to "empty" the breast: that increases milk production and swelling.
Ice or cold packs, ibuprofen and/or acetaminophen; supportive bra.
Avoid heat and deep massage; very gentle lymphatic drainage strokes only.
Antibiotics (e.g., cephalexin or dicloxacillin) if not improving in 12–24 h or systemically unwell; a lump that doesn't resolve → ultrasound for abscess.

Mood after birth

Baby blues	Up to ~80%. Tearful, mood swings in the first days; gone by ~2 weeks. Reassure, rest, support.
Postpartum depression	Lasts >2 weeks and affects functioning. Screen (e.g., Edinburgh scale). Therapy; SSRIs (sertraline is compatible with breastfeeding); zuranolone (oral, 14 days). New
Postpartum psychosis	Emergency. Hallucinations, delusions, confusion, risk to self or baby. Don't leave her alone with the baby.

Before discharge

Rh immune globulin within 72 h if she is Rh-negative and the baby is Rh-positive.
MMR if not rubella-immune (avoid pregnancy for 1 month; breastfeeding is fine); Tdap if not given.
Contraception: progestin-only methods can start anytime; combined estrogen methods not before 3 weeks (later if breastfeeding or VTE risk).
Warning signs: chest pain or SOB, seizure, thoughts of harming self or baby, soaking a pad in an hour, red swollen leg, temp ≥100.4°F (38°C), severe headache or vision change.

Gestational Diabetes and Pregnancy Bleeding

Screening and management; bleeding in the first and second half

Maternity

Gestational diabetes: screening at 24–28 weeks

Earlier testing if high risk. Two accepted approaches:

One-step	75 g 2-hour OGTT (fasting). Positive if any: fasting ≥92, 1 h ≥180, 2 h ≥153 mg/dL
Two-step	50 g 1-hour screen (no fasting); if ≥130–140 → 100 g 3-hour OGTT. Diagnosis needs ≥2 abnormal values

An abnormal 1-hour screen is not a diagnosis: it leads to the 3-hour test.

Management

Targets: fasting <95; 1 h after meals <140; 2 h <120 mg/dL.
Nutrition therapy, carbohydrate spread across meals and snacks, regular activity.
Insulin is the preferred drug (doesn't cross the placenta). Metformin and glyburide cross the placenta: second-line.
Risks: big baby, shoulder dystocia, preeclampsia, newborn hypoglycemia, stillbirth.
75 g OGTT 4–12 weeks postpartum; lifelong type 2 diabetes risk, so screen every 1–3 years.

Bleeding in early pregnancy

Condition	Clues	Care
Miscarriage	Cramping, bleeding; threatened (closed cervix) → inevitable/incomplete (open)	Support; monitor bleeding; Rh immune globulin per protocol
Ectopic pregnancy	One-sided pelvic pain, spotting; shoulder pain, dizziness, hypotension = rupture	Stable and unruptured: methotrexate (no alcohol, folic acid or NSAIDs; follow hCG). Ruptured: emergency surgery
Molar pregnancy	Very high hCG, uterus larger than dates, severe vomiting, early preeclampsia, dark brown bleeding	Evacuation; follow hCG to zero; reliable contraception during follow-up

Bleeding in later pregnancy

	Placenta previa	Placental abruption
What	Placenta over or near the cervix	Placenta separates early from the uterine wall
Pain	Painless	Painful, tender
Blood	Bright red	Dark; may be hidden (concealed)
Uterus	Soft, relaxed	Rigid, board-like
Risks	Previous cesarean, multiparity, multiples	Hypertension, cocaine, smoking, trauma
Nursing	No vaginal exams until previa is ruled out by ultrasound; cesarean birth	Emergency: fetal distress, shock, DIC

DIC labs

↓ platelets, ↓ fibrinogen, prolonged PT/aPTT, ↑ D-dimer. Bleeding from IV sites, gums, petechiae. Treat the cause; blood products.

Priority Any second-half bleeding: left side, monitor FHR and vital signs, IV access, notify, and no vaginal exam until the placenta's location is known.

Newborn Care

The first hours and days

Maternity

APGAR (1 and 5 minutes)

Sign	0	1	2
Heart rate	Absent	<100	≥100
Resp. effort	Absent	Weak, irregular	Good cry
Muscle tone	Limp	Some flexion	Active motion
Reflex irritability	None	Grimace	Cry, cough, sneeze
Color	Blue/pale	Blue hands and feet	Pink all over

7–10 normal · 4–6 moderate · 0–3 severe. Resuscitation never waits for the APGAR.

Normal values

Heart rate	~100–160/min (lower asleep, higher crying)
Respirations	30–60/min; brief pauses <20 s normal
Temperature	97.7–99.5°F (36.5–37.5°C) axillary
Weight loss	Up to ~7–10% in the first days; regained by 10–14 days

Normal findings: acrocyanosis, molding, milia, erythema toxicum, Epstein pearls, small vaginal discharge or bleeding (maternal hormones). Caput crosses suture lines; cephalohematoma doesn't (and raises jaundice risk).

Routine newborn medications and screening

Vitamin K	Single IM dose (0.5–1 mg) into the vastus lateralis within ~6 h: prevents vitamin K deficiency bleeding
Eye prophylaxis	Erythromycin 0.5% ophthalmic ointment within 1–2 h of birth (required by law in many states)
Hepatitis B	Birth dose within 24 h for medically stable newborns ≥2,000 g (AAP; what NCLEX tests). Mother HBsAg-positive: vaccine + HBIG within 12 h; status unknown: vaccine within 12 h. A Dec 2025 ACIP change (shared decision-making if the mother is HBsAg-negative) was blocked by a federal court in March 2026; check the current CDC schedule. Updated
RSV protection	Nirsevimab (or clesrovimab) IM for infants entering their first RSV season, unless the mother had the RSV vaccine ≥14 days before birth New
Screening	Newborn blood spot after 24 h of feeding; hearing; critical congenital heart disease pulse oximetry at ≥24 h (right hand and a foot)

Hypoglycemia

At risk: infant of diabetic mother, small or large for dates, preterm, cold stress. Signs: jitteriness, poor feeding, floppy, apnea, high-pitched cry, temperature instability, seizures (or none). Check glucose early per protocol; feed; 40% dextrose gel to the cheek; IV dextrose if severe or persistent.

Jaundice

Within the first 24 h = pathologic: report now. Physiologic jaundice appears after 24 h and peaks day 3–5. Phototherapy: eye shields, maximum skin exposure, turn, feed often, monitor temperature and hydration. Treat by hour-specific bilirubin thresholds (AAP 2022).

Keeping baby warm and safe

Dry immediately; skin-to-skin; hat; warm room. Heat loss: evaporation, conduction, convection, radiation.
Safe sleep: on the back, firm flat surface, own sleep space in the parents' room, nothing soft in the crib, no smoking, avoid overheating.
Cord: dry cord care: keep clean and dry, fold the diaper below the stump; falls off in ~10–14 days. Report redness, odor or drainage.
Rear-facing car seat required for discharge; back seat, harness snug at the armpits.

Newborn reflexes

Moro (startle; gone by ~4–6 months) · rooting and sucking (~4 months) · palmar grasp (~3–4 months) · plantar grasp (~8–10 months) · tonic neck ("fencing", ~4–6 months) · stepping (~2 months) · Babinski (toes fan out: normal until ~1–2 years). An absent or one-sided Moro may mean injury (clavicle fracture, brachial plexus).

Pediatric Vital Signs and Safety

Normal ranges, pain scales and safe medication dosing

Pediatrics

Approximate normal vital signs (awake, at rest)

Age	Heart rate	Respirations	Hypotension if systolic BP below
Newborn (0–28 days)	100–160	30–60	60
Infant (1–12 months)	100–160	30–50	70
Toddler (1–2 yr)	90–150	24–40	70 + (2 × age in years)
Preschool (3–5 yr)	80–140	22–34	70 + (2 × age in years)
School age (6–12 yr)	70–120	18–30	70 + (2 × age) up to 10 yr; then 90
Adolescent (13–18 yr)	60–100	12–20	90

Ranges vary between references; know your facility's chart. Count infant respirations and apical pulse for a full minute. Children compensate well, then crash: hypotension is a late sign of shock; tachycardia and delayed capillary refill come first.

Pain assessment

FLACC	Pre-verbal or non-verbal (2 months–7 yr): Face, Legs, Activity, Cry, Consolability
Wong-Baker FACES	~3 years and older
Numeric 0–10	~8 years and older (who understand numbers)
Neonates	NIPS, PIPP, or similar

Non-drug comfort: breastfeeding or sucrose for infants during procedures, skin-to-skin, distraction, topical anesthetic before needles.

Safe dosing

Doses are weight-based (mg/kg): weigh in kilograms and record kg only.
Calculate the safe dose range and compare it with the order before giving.
Never exceed the adult maximum dose.
Oral liquids: use an oral syringe or the device supplied, never a kitchen spoon. Check the concentration.

Example: 22 lb child → 10 kg. Acetaminophen 15 mg/kg = 150 mg. Liquid 160 mg/5 mL → 150 ÷ 160 × 5 = 4.7 mL.

Development: the nursing angle

Infant	Trust; stranger anxiety from ~6–8 months: keep parent present
Toddler	Autonomy; separation anxiety; simple choices; rituals
Preschool	Magical thinking (may see illness as punishment); use dolls to explain
School age	Industry; explain with simple science; involve in care
Adolescent	Identity; privacy; interview alone for part of the visit; body image

Priority Most pediatric cardiac arrests start as respiratory failure or shock. Watch for: increasing work of breathing, grunting, nasal flaring, retractions, head bobbing, decreasing level of consciousness, and a falling heart rate in a hypoxic child (pre-arrest).

Congenital Heart Defects

Acyanotic vs. cyanotic, and what the nurse watches for

Pediatrics

Acyanotic (left-to-right shunt or obstruction)

VSD	Most common CHD. Loud holosystolic murmur; may close on its own; large ones cause HF
ASD	Often silent in childhood; soft murmur
PDA	"Machinery" murmur, bounding pulses; common in preterm infants
Coarctation of aorta	High BP and bounding pulses in the arms; weak or absent femoral pulses; low BP in the legs
Aortic / pulmonary stenosis	Murmur; exercise intolerance; HF if severe

ASD, VSD and PDA are acyanotic: extra blood goes to the lungs (risk of heart failure), not blue blood to the body.

Cyanotic (deoxygenated blood reaches the body)

Tetralogy of Fallot	Pulmonary stenosis, VSD, overriding aorta, right ventricular hypertrophy. "Tet spells"
Transposition of great arteries	Severe cyanosis at birth; needs a mixing site (PDA/ASD); arterial switch surgery
Tricuspid atresia	Cyanosis; staged surgery
Truncus arteriosus	Single great vessel; cyanosis and HF
Hypoplastic left heart	Underdeveloped left side; duct-dependent; staged surgery (Norwood, Glenn, Fontan)

Tet spell (hypercyanotic episode)

Knee-chest position (older children squat): ↑ systemic resistance, more blood to the lungs.
Keep calm; parent holds the child.
Oxygen.
Morphine, IV fluids, and other drugs as ordered.

Duct medicines

To close a PDA (preterm): indomethacin, ibuprofen, or acetaminophen.
To keep it open in duct-dependent defects: prostaglandin E1 (alprostadil) infusion. Watch for apnea, fever, flushing, low BP.

Heart failure in infants

Tachypnea and sweating during feeds, poor feeding, poor weight gain, tachycardia, hepatomegaly, irritability. (Peripheral edema is less common than in adults.)
Small frequent feeds; higher-calorie formula or fortified breast milk; tube feeds if tiring; rest; daily weight.
Digoxin: count the apical pulse for 1 full minute; hold and notify per parameters (commonly infant <90–110, child <70); vomiting or poor feeding can be early toxicity. Furosemide: watch K⁺.

Kawasaki disease (acquired)

Fever ≥5 days + features: red eyes without discharge, red cracked lips and "strawberry tongue", rash, swollen hands and feet then peeling, a large neck lymph node.
Danger: coronary artery aneurysms (echocardiograms).
Treatment: IVIG + aspirin (one of the few times aspirin is used in children).
Delay live vaccines (MMR, varicella) ~11 months after IVIG. Report flu or chickenpox exposure while on aspirin (Reye's syndrome).

Memory hook Cyanotic defects start with T: Tetralogy, Transposition, Tricuspid atresia, Truncus, Total anomalous pulmonary venous return. The most common congenital birth defect overall is a heart defect (about 1 in 100 births).

Pediatric CPR and Choking

2025 AHA Pediatric Basic Life Support

Pediatrics

Who counts as what

Infant: under 1 year (excluding newborns at birth).
Child: 1 year to puberty (breast development in girls, underarm hair in boys).
Adolescents after puberty: use adult BLS.

Check

Pulse: brachial (infant), carotid or femoral (child), up to 10 sec.
Start compressions if no pulse, or HR <60 with poor perfusion despite good ventilation.

Compressions

Rate	100–120/min, full recoil
Depth	At least ⅓ of chest depth: ~1.5 in (4 cm) infant, ~2 in (5 cm) child
Ratio	30:2 one rescuer · 15:2 two rescuers
Infant hands Updated	Two-thumb encircling hands, or the heel of one hand. The two-finger technique is no longer recommended (2025)
Child hands	One or two hands, lower half of sternum

Breathing

Pulse present but not breathing well: 1 breath every 2–3 sec (20–30/min).
With an advanced airway during CPR: 1 breath every 2–3 sec, compressions continuous.
Just enough to make the chest rise. Over-ventilation is harmful.

Calling for help and the AED

Alone, unwitnessed arrest: give 2 min of CPR first, then call and get the AED (likely respiratory cause).
Sudden witnessed collapse: call and get the AED first (likely cardiac).
AED: pediatric pads or dose attenuator for children <8 years if available; otherwise use adult pads (front and back if they would touch).

Choking (foreign-body airway obstruction)

Infant, responsive

5 back blows (face-down along your forearm, head lower than chest) then 5 chest thrusts; repeat.
No abdominal thrusts in infants.

Child, responsive

Back blows and abdominal thrusts: alternate cycles of 5 and 5 (2025 AHA) until the object comes out or the child becomes unresponsive.

If they become unresponsive

Lower to the floor, call for help, start CPR (compressions).
Before each set of breaths, look in the mouth: remove an object only if you can see it.
No blind finger sweeps.

A child who can cough forcefully or cry: let them keep coughing and stay with them.

PALS doses to recognize

Epinephrine	0.01 mg/kg IV/IO (0.1 mL/kg of 0.1 mg/mL) every 3–5 min
Amiodarone	5 mg/kg (VF/pulseless VT)
Defibrillation	2 J/kg, then 4 J/kg (max 10 J/kg or adult dose)
Fluid bolus	10–20 mL/kg isotonic crystalloid; reassess after each

Memory hook "Two hands, two thumbs, 15:2 for two." Infants: two-thumb encircling (or heel of one hand). Two rescuers on a child or infant: 15 compressions to 2 breaths.

Pediatric Respiratory Illness

Bronchiolitis, croup, epiglottitis and foreign bodies

Pediatrics

Bronchiolitis (usually RSV, under 2 years)

Starts like a cold, then cough, wheeze, crackles, tachypnea, retractions, nasal flaring, poor feeding.
Apnea can be the first sign in young or preterm infants.
Worst around days 3–5.

Care is supportive

Nasal suctioning (saline + bulb) before feeds and sleep.
Hydration: small frequent feeds; NG or IV fluids if needed.
Oxygen if SpO₂ stays <90%; high-flow nasal cannula for more severe cases.
Contact precautions; hand hygiene; cluster care.

Updated: not routinely recommended Corticosteroids, albuterol, antibiotics (unless bacterial infection), and chest physiotherapy don't help typical bronchiolitis (AAP). Older guides that list steroids are out of date.

Prevention New

RSV vaccine in pregnancy (32–36 wk) or a long-acting antibody for the baby (nirsevimab or clesrovimab) before or during the first RSV season.

Croup (laryngotracheobronchitis)

Usually parainfluenza virus; 6 months–3 years.
Barking, seal-like cough, hoarse voice, inspiratory stridor; worse at night.
Dexamethasone single dose (oral or IM) for all severities.
Nebulized epinephrine for stridor at rest; observe 2–4 h after (symptoms can return).
Keep the child calm, on the parent's lap. Mist therapy isn't proven.

Epiglottitis: airway emergency

Sudden high fever, toxic look; the 4 Ds: drooling, dysphagia, dysphonia (muffled voice), distress; tripod position.
Do not put anything in the mouth or examine the throat (no tongue blade, no throat swab): it can cause complete obstruction.
Keep upright and calm; emergency airway equipment at the bedside; intubation in a controlled setting; IV antibiotics.
Rare now thanks to the Hib vaccine.

Foreign-body aspiration

Sudden cough, choking or wheeze in a toddler, often one-sided decreased breath sounds. Prevent: no nuts, whole grapes, hard candy, popcorn or small toys for under 4s; cut food small.

Priority Stridor at rest, drooling, tripod position, silent chest, or a falling SpO₂ in a tiring child → call for help now. Don't upset the child: crying worsens obstruction.

Fever, Dehydration and Fluids

Comfort, safe antipyretic use, and rehydration

Pediatrics

Fever

Fever = ≥100.4°F (38.0°C).
Infant <28 days with fever: full sepsis work-up. Up to 60–90 days: urgent evaluation.
Treat the child's discomfort, not the number. Fever itself isn't harmful in most children.
Light clothing, fluids, rest.

UpdatedNo tepid sponging, cold baths or alcohol rubs: they cause shivering and discomfort (alcohol can be absorbed and is toxic) and don't help.

Antipyretics

Acetaminophen	10–15 mg/kg every 4–6 h; max 5 doses in 24 h (≤75 mg/kg/day, never more than 4 g)
Ibuprofen	5–10 mg/kg every 6–8 h; max 40 mg/kg/day. Only from 6 months; give with food; avoid if dehydrated
Aspirin	Never for fever in children and teens (Reye's syndrome)

Febrile seizure

6 months–5 years; brief, generalized. Side-lying, protect the head, nothing in the mouth, time it; call for help if >5 min. Antipyretics don't prevent them.

How dehydrated?

	Mild (3–5%)	Moderate (6–9%)	Severe (≥10%)
Behavior	Alert	Irritable, thirsty	Lethargic
Mucous membranes	Slightly dry	Dry; ↓ tears	Parched; no tears
Eyes / fontanel	Normal	Sunken	Very sunken
Capillary refill	<2 s	2–3 s	>3 s; cool, mottled skin
Heart rate / BP	Normal	Tachycardia	Tachycardia; low BP (late)
Urine output	Slightly ↓	↓	Minimal or none

Oral rehydration (mild–moderate)

ORS 50 mL/kg (mild) or 100 mL/kg (moderate) over 3–4 h, in small frequent sips (5 mL every 1–2 min by spoon or syringe).
Replace ongoing losses (~10 mL/kg per loose stool).
Continue breastfeeding and normal diet once rehydrated.
Avoid juice, soda and sports drinks (too much sugar).

IV fluids

Severe dehydration or shock: 10–20 mL/kg isotonic bolus (normal saline or lactated Ringer's); reassess and repeat.
Maintenance (Holliday-Segar): 100 mL/kg/day for the first 10 kg + 50 mL/kg/day for the next 10 kg + 20 mL/kg/day for each kg above 20.
Example, 25 kg: 1,000 + 500 + 100 = 1,600 mL/day (~65 mL/h).
Isotonic maintenance fluids are now preferred (lower risk of hyponatremia). Updated
Add potassium only after the child voids.

Memory hook Best measure of fluid status: daily weight (1 kg ≈ 1 L). Minimum urine output: ~1 mL/kg/h for infants and children, 0.5 mL/kg/h for adolescents. Count wet diapers (weigh them: 1 g = 1 mL).

Cystic Fibrosis

A genetic disease of thick secretions, now transformed by CFTR modulators

Pediatrics

The basics

Autosomal recessive (CFTR gene). Two carrier parents: 25% chance each pregnancy.
Thick, sticky secretions block the lungs, pancreas, intestines, liver and reproductive tract.

Signs

Meconium ileus at birth (often the first sign).
Salty-tasting skin.
Poor growth despite a big appetite; bulky, greasy, foul-smelling stools (steatorrhea).
Chronic cough, repeated lung infections (Staph aureus, Pseudomonas), clubbing, nasal polyps.
Most males are infertile (absent vas deferens).

Diagnosis

Newborn screening (IRT blood test) → sweat chloride test.
Sweat chloride ≥60 mmol/L = CF; 30–59 = intermediate (needs more testing).
Genetic testing confirms the mutations.

CFTR modulators New

Fix the faulty protein for most mutations: elexacaftor/tezacaftor/ivacaftor (Trikafta) from age 2, and vanzacaftor/tezacaftor/deutivacaftor (Alyftrek) from age 6. Big gains in lung function, weight and survival. Monitor liver tests and eye exams (cataracts in children).

Lungs: airway clearance every day

Chest physiotherapy, oscillating vest or PEP device, huff coughing, exercise: usually 1–2+ times a day.
Usual order: bronchodilator → hypertonic saline → dornase alfa → airway clearance → inhaled antibiotic (e.g., tobramycin) → inhaled steroid if used.
Airway clearance before meals (or 1 h after) to avoid vomiting.
Infection control: people with CF keep ≥6 ft (2 m) apart from each other (cross-infection); contact precautions in hospital.

Pancreas and nutrition

Pancreatic enzymes (pancrelipase) with every meal and snack, at the start of eating.
Swallow capsules whole, or open and sprinkle beads on a small amount of acidic soft food (applesauce). Don't crush or chew the beads; don't mix with milk.
Adjust dose to stools (fewer greasy stools = right dose).
High-calorie, high-protein, high-fat (unrestricted fat) diet, individualized (some people on modulators now gain too much weight); extra salt in hot weather, fever or exercise.
CF-specific fat-soluble vitamins A, D, E, K.

Complications

CF-related diabetes (yearly screening from age 10) · distal intestinal obstruction · liver disease · low bone density · pneumothorax · hemoptysis · depression and anxiety (screen).

Memory hook Salty, skinny, stinky, sticky: salty skin, poor growth, greasy stools, thick mucus.

Immunization Principles

Principles and the US routine childhood schedule (CDC/AAP)

Pediatrics

Live vaccines

MMR, varicella, rotavirus (oral), live nasal influenza (LAIV), yellow fever, oral typhoid. (BCG and oral polio are not used routinely in the US.)

Not in pregnancy or severe immunosuppression (e.g., chemotherapy, high-dose steroids).
Two live injected vaccines: same day or ≥28 days apart.
After blood products or IVIG: live vaccines may need to be delayed (months).

Contraindications vs. not

True contraindication: severe allergic reaction (anaphylaxis) to a previous dose or a vaccine component.

Precaution: moderate or severe acute illness (delay).

Not reasons to delay: mild illness or low fever, taking antibiotics, breastfeeding, prematurity (vaccinate by chronological age), egg allergy (any flu vaccine can be given).

Giving the injection

Who	IM site	Needle (typical)
Newborns and infants	Vastus lateralis (anterolateral thigh)	⅝–1 in, 22–25 G
Toddlers 1–2 yr	Vastus lateralis (preferred) or deltoid if enough muscle	⅝–1¼ in
3 years and older	Deltoid (thigh if needed)	⅝–1 in

Subcutaneous vaccines (MMR, varicella): fatty tissue of the thigh (infants) or upper outer arm.
Rotavirus is oral: first dose by 14 weeks 6 days; last dose by 8 months.
No need to aspirate. Give the most painful vaccine last. Comfort: breastfeeding, sucrose, holding, distraction.
Observe 15 minutes (adolescents seated: fainting risk). Keep epinephrine available.
Document vaccine, lot, site, date and the information given.

US routine childhood schedule (AAP / CDC)

Age	Vaccines
Birth	Hep B #1 (within 24 h) · RSV antibody (nirsevimab or clesrovimab) Oct–Mar if mother not vaccinated
1–2 months	Hep B #2
2 months	DTaP, Hib, IPV, PCV, rotavirus
4 months	DTaP, Hib, IPV, PCV, rotavirus
6 months	DTaP, PCV, Hib and rotavirus (brand-dependent) · Hep B #3 and IPV #3 (6–18 mo) · influenza yearly from 6 months (2 doses the first season if <9 yr)
12–15 months	MMR #1, varicella #1, Hib and PCV boosters · Hep A (2 doses, 6 months apart, by 23 mo)
15–18 months	DTaP #4
4–6 years	DTaP #5, IPV #4, MMR #2, varicella #2
11–12 years	Tdap, HPV (can start at 9), MenACWY #1
16 years	MenACWY booster · MenB (16–23 yr, shared decision)

Also: Tdap in every pregnancy (27–36 wk); COVID-19 vaccination per current CDC/AAP guidance.

US schedule in 2026 Federal changes to the childhood schedule (Dec 2025 ACIP votes and a Jan 2026 CDC schedule) were blocked by a federal court in March 2026, restoring the previous schedule while appeals continue. The AAP schedule above reflects standard teaching and NCLEX. Check the current CDC/AAP schedule before clinicals.

Antidotes and Drug Levels

Reversal agents and therapeutic ranges you're expected to know

Pharmacology

Antidotes and reversal agents

Drug or poison	Antidote
Opioids	Naloxone (may need repeat doses: it wears off before many opioids)
Benzodiazepines	Flumazenil (can trigger seizures in long-term users)
Acetaminophen	Acetylcysteine (best within 8 h)
Heparin	Protamine sulfate (partial for enoxaparin)
Warfarin	Vitamin K; 4-factor PCC for serious bleeding
Dabigatran	Idarucizumab
Apixaban, rivaroxaban	4-factor PCC (andexanet alfa was withdrawn from the US market in Dec 2025)
Digoxin	Digoxin immune fab
Beta blockers	Glucagon (also calcium, high-dose insulin)
Calcium channel blockers	Calcium, high-dose insulin, glucagon
Insulin, sulfonylureas	Glucose / glucagon; octreotide for sulfonylureas
Magnesium sulfate	Calcium gluconate

Drug or poison	Antidote
Anticholinergics	Physostigmine
Organophosphates, cholinergic crisis	Atropine + pralidoxime
Tricyclic antidepressants	Sodium bicarbonate (wide QRS)
Aspirin (salicylates)	Sodium bicarbonate; dialysis if severe
Iron	Deferoxamine
Lead	Succimer, edetate calcium disodium, dimercaprol
Cyanide (incl. nitroprusside)	Hydroxocobalamin
Methanol, ethylene glycol	Fomepizole
Methotrexate	Leucovorin
Isoniazid overdose	Pyridoxine (vitamin B6)
Local anesthetic toxicity	Lipid emulsion 20%
Malignant hyperthermia	Dantrolene
Serotonin syndrome	Cyproheptadine + supportive care

Therapeutic drug levels

Digoxin	0.5–2.0 ng/mL (0.5–0.9 target in HF)
Lithium	0.6–1.2 mEq/L; toxic >1.5
Phenytoin	10–20 mcg/mL
Valproic acid	50–100 mcg/mL
Carbamazepine	4–12 mcg/mL
Theophylline	10–20 mcg/mL (many now aim 5–15)
Vancomycin	AUC 400–600 (trough-based dosing in some settings)
Gentamicin	Depends on regimen; low trough (<1–2 mcg/mL)

Coagulation targets

Heparin	aPTT ~1.5–2.5 × control, or anti-Xa 0.3–0.7 (per protocol)
Warfarin	INR 2–3; 2.5–3.5 for some mechanical valves (e.g., mitral)
Normal INR	~0.8–1.1 (not on warfarin)

Timing

Trough: just before the next dose (lowest level).
Peak: at a set time after the dose (e.g., 30 min after an IV infusion ends).
High trough = toxicity risk; low peak = not effective.

Memory hook "Protamine for the Hep (you need a pro to stop heparin)" · "K kills warfarin's effect" · "Glucagon for beta blockers and insulin" · "Calcium calms magnesium."

Blood Pressure Medications

Classes, side effects, and what to teach

Pharmacology

Class	Examples	Key side effects and nursing points
ACE inhibitors (-pril)	lisinopril, enalapril, ramipril, captopril	Dry cough; angioedema (stop, protect airway; can happen any time); ↑ K⁺; first-dose hypotension; small creatinine rise is expected. Teratogenic. Avoid potassium supplements and salt substitutes.
ARBs (-sartan)	losartan, valsartan, olmesartan	Like ACE inhibitors but cough is rare. Never combine an ACE inhibitor + ARB. Teratogenic.
ARNI	sacubitril/valsartan	For HFrEF. 36-hour gap after stopping an ACE inhibitor.
Beta blockers (-olol)	Cardioselective (β1): metoprolol, atenolol, bisoprolol. Non-selective: propranolol, nadolol; carvedilol and labetalol also block α1	Bradycardia, hypotension, fatigue; bronchospasm (non-selective, caution in asthma); masks hypoglycemia (tachycardia, tremor; sweating still occurs). Don't stop abruptly (rebound tachycardia, angina). Hold per parameters (often HR <60, SBP <90–100).
Dihydropyridine CCBs (-dipine)	amlodipine, nifedipine	Ankle edema, flushing, headache, reflex tachycardia, gum overgrowth. Immediate-release nifedipine is not for chronic BP control.
Non-dihydropyridine CCBs	diltiazem, verapamil	Slow the heart: bradycardia, heart block; constipation (verapamil). Avoid in HFrEF. Grapefruit interaction.
Thiazide diuretics	chlorthalidone, hydrochlorothiazide	↓ K⁺, ↓ Na⁺, ↑ Ca²⁺, ↑ glucose, ↑ uric acid (gout); see Diuretics.
Alpha-1 blockers (-osin)	doxazosin, prazosin, terazosin	First-dose orthostatic hypotension: take at bedtime. Also used for BPH (tamsulosin).
Central alpha-2 agonists	clonidine, methyldopa	Drowsiness, dry mouth, bradycardia. Clonidine: severe rebound hypertension if stopped suddenly. Methyldopa is used in pregnancy.
Direct vasodilators	hydralazine, minoxidil, nitroprusside (IV)	Reflex tachycardia, fluid retention. Hydralazine: lupus-like syndrome. Nitroprusside: ICU only, protect from light, cyanide toxicity.

Teaching for every BP drug

Change position slowly; sit before standing; dangle legs.
Don't stop suddenly (especially beta blockers, clonidine).
Keep a home BP log; report dizziness or fainting.
Avoid NSAIDs and decongestants (raise BP; NSAIDs harm kidneys with ACEi/ARB + diuretic).
Limit alcohol and salt; take as prescribed even when feeling well.

Special situations

Pregnancy: labetalol, extended-release nifedipine, methyldopa. No ACE inhibitors, ARBs, ARNI.
Diabetes or CKD with protein in urine: ACE inhibitor or ARB preferred.
Asthma: avoid non-selective beta blockers.
Gout: thiazides can trigger attacks; losartan lowers uric acid.
Angioedema history: no ACE inhibitors or ARNI.

Memory hook ACE inhibitors cause a "hacking cough" and keep K⁺ (potassium) in: "ACE = Angioedema, Cough, Elevated potassium."

Diuretics and Other Cardiac Drugs

Diuretics, antiarrhythmics, nitrates and vasoactive infusions

Pharmacology

Diuretics

Type	Examples	Key points
Loop	furosemide, bumetanide, torsemide	Act on the thick ascending loop of Henle; most potent. ↓ K⁺, ↓ Mg²⁺, ↓ Na⁺, dehydration, hypotension, ↑ glucose and uric acid. Ototoxicity with rapid IV push or high doses: give IV slowly. Low K⁺ raises digoxin toxicity.
Thiazide	hydrochlorothiazide, chlorthalidone, metolazone	Act on the distal convoluted tubule. ↓ K⁺, ↓ Na⁺, ↑ Ca²⁺, ↑ glucose, ↑ uric acid, photosensitivity. Raise lithium levels.
Potassium-sparing	spironolactone, eplerenone, amiloride, triamterene	↑ K⁺: no potassium supplements or salt substitutes; caution with ACEi/ARB. Spironolactone: gynecomastia, menstrual changes.
Osmotic	mannitol	↓ intracranial and intraocular pressure. Use an in-line filter (crystals). Watch for fluid overload and pulmonary edema, electrolytes, osmolality.
Carbonic anhydrase inhibitor	acetazolamide	Glaucoma, altitude sickness. Metabolic acidosis, low K⁺, tingling.

All diuretics: give in the morning (avoid nocturia), daily weight, I&O, BP, electrolytes. Sulfa allergy is not a reliable reason to avoid loop or thiazide diuretics (cross-reactivity is not supported). Updated

Amiodarone

For VT/VF and atrial fibrillation. Long half-life (weeks to months).

Lungs: pulmonary toxicity (cough, dyspnea): baseline chest X-ray and lung tests.
Thyroid: hypo- or hyperthyroidism (it contains iodine): check TSH.
Liver tests; eyes (corneal deposits, optic neuropathy); skin (photosensitivity, blue-gray color).
Bradycardia, QT prolongation; IV can cause hypotension.
Raises warfarin and digoxin levels: doses need lowering.

Nitrates

Sublingual tablet or spray: 1 dose every 5 min, max 3; call emergency services if pain isn't better 5 min after the first dose.
Store tablets in the original dark glass bottle.
Patch/ointment: rotate sites, remove the old one, wear gloves; plan a nitrate-free period (usually 10–12 h overnight) to prevent tolerance.
Headache (expected; acetaminophen), hypotension, dizziness.
Never with PDE-5 inhibitors (sildenafil, vardenafil within 24 h; tadalafil within 48 h).

Vasoactive infusions (ICU)

Norepinephrine	First-line in septic shock. Vasoconstrictor. Extravasation → tissue necrosis: stop, leave the catheter, give phentolamine per protocol
Epinephrine	Anaphylaxis (IM 0.3–0.5 mg of 1 mg/mL in adults), cardiac arrest, shock
Vasopressin	Added to norepinephrine in septic shock
Dobutamine	Inotrope (↑ contractility) for cardiogenic shock and HF; can cause tachycardia, dysrhythmias
Dopamine	Bradycardia or shock (second-line); dose-dependent effects

Use a central line when possible, an infusion pump, and frequent BP (often an arterial line). Typical target: MAP ≥65 mmHg.

Priority Before digoxin: apical pulse 1 full minute (hold if <60 in adults) and check K⁺. Before a beta blocker or diltiazem: HR and BP. Before a diuretic: K⁺ and BP. Assess first, then give.

Anticoagulants, Antiplatelets and Thrombolytics

Prevent clots, stop clot growth, or dissolve clots

Pharmacology

Anticoagulants

Drug	Route / monitoring	Key points
Heparin (unfractionated)	IV infusion or SC; aPTT or anti-Xa; platelets	Fast onset; protocol-based dosing. HIT: platelets fall >50% (usually day 5–10) or new clots → stop all heparin (including flushes), use argatroban or bivalirudin. Safe in pregnancy. Antidote: protamine.
Enoxaparin (LMWH)	SC; usually no routine labs (anti-Xa in kidney disease, obesity, pregnancy)	Abdomen ≥2 in (5 cm) from the umbilicus; don't expel the air bubble in the prefilled syringe; don't rub. Lower dose if CrCl <30. Spinal/epidural hematoma risk around neuraxial anesthesia.
Warfarin	Oral; PT/INR	Blocks vitamin K–dependent factors (II, VII, IX, X). Takes days to work: overlap with heparin/LMWH until INR is therapeutic. Teratogenic (OK in breastfeeding). Keep vitamin K intake consistent (don't avoid greens, just keep them steady). Many interactions: antibiotics, amiodarone, NSAIDs, alcohol, herbals.
DOACs: apixaban, rivaroxaban, edoxaban, dabigatran	Oral; no routine INR	Fewer interactions and fewer brain bleeds than warfarin (GI bleeding can be higher with some). Not for mechanical heart valves or pregnancy. Rivaroxaban 15/20 mg with food. Dabigatran: keep in the original bottle, don't open capsules. Doses adjusted for kidney function.

Antiplatelets

Aspirin	Irreversible; effect lasts the platelet's life (7–10 days)
Clopidogrel	Prodrug; omeprazole/esomeprazole reduce its effect (pantoprazole preferred)
Prasugrel	Not with prior stroke/TIA; caution age ≥75 or weight <60 kg
Ticagrelor	Twice daily; shortness of breath; keep aspirin ≤100 mg
Cilostazol	Leg claudication; contraindicated in HF

After a coronary stent: never stop antiplatelets without the cardiologist (stent thrombosis).

Thrombolytics

Alteplase (stroke, STEMI, massive PE); tenecteplase (stroke, STEMI); reteplase (STEMI only). Dissolve existing clots.

Contraindications (examples): active bleeding, any prior brain hemorrhage, recent stroke, surgery or trauma, brain tumor, severe uncontrolled BP, bleeding disorder.

Nursing: place IV lines before; avoid IM injections and new punctures; neuro checks; watch for bleeding (gums, IV sites, urine, stool, neuro change). Stroke timing: within 4.5 h of last known well.

Bleeding precautions (teach)

Soft toothbrush; electric razor; gentle flossing with waxed floss.
Avoid contact sports and fall hazards.
No NSAIDs or aspirin unless prescribed; check with the pharmacist before herbal products.
Report: black or bloody stools, blood in urine, coffee-ground vomit, nosebleeds that won't stop, unusual bruising, severe headache.
Wear medical ID; tell all providers and the dentist.

Memory hook Warfarin → PT/INR ("WarPed Time"); heparin → aPTT.
Warfarin needs Waiting (slow onset); Heparin Happens fast.

Insulin

Types, mixing, injecting, and handling hypoglycemia

Pharmacology

Insulin types (approximate times)

Type	Examples	Onset	Peak	Duration	Notes
Rapid-acting	lispro, aspart, glulisine	~15 min	1–2 h	3–5 h	Give within 15 min of a meal; food must be ready
Short-acting	regular	30–60 min	2–4 h	5–8 h	30 min before meals. Used in IV infusions (DKA)
Intermediate	NPH	1–2 h	4–12 h	12–18 h	Cloudy: roll gently to mix; peak = hypoglycemia risk
Long-acting	glargine, degludec (detemir discontinued in the US)	1–2 h	No real peak	~24 h (degludec up to 42 h)	Basal dose. Never mix with other insulins

Mixing NPH and regular in one syringe

Inject air into NPH (cloudy). Don't draw up.
Inject air into regular (clear) and draw up the regular dose.
Then draw up the NPH dose.

Memory hook"Clear before cloudy", or R before N, like an RN. Never contaminate the clear vial with cloudy insulin.

Giving insulin

Subcutaneous: abdomen (fastest, ≥2 in from the umbilicus), back of arms, thighs, buttocks.
Rotate sites within an area (lumps of fat called lipohypertrophy cause erratic absorption).
Pens: prime 2 units; hold the needle in for ~10 sec.
High-alert: independent double check per policy; always use "units", never "U".
Storage: unopened in the fridge (don't freeze); in-use pen or vial at room temperature for the time on the label (often 28 days).

Hypoglycemia (<70 mg/dL)

Signs: shaky, sweaty, fast heartbeat, anxious, hungry, headache, confused, irritable → seizures, coma. Beta blockers can hide the warning signs.

Awake and can swallow: 15 g fast carbohydrate (4 oz/120 mL juice or regular soda, glucose tablets).
Recheck in 15 min; repeat if still <70.
Once normal: a snack or meal with protein and carbohydrate.
Can't swallow or unconscious: glucagon (IM, SC or nasal) or IV dextrose; turn on the side.

In the hospital

Typical target for most inpatients: 140–180 mg/dL.
Basal + mealtime + correction insulin is preferred over sliding-scale insulin alone. Updated
NPO: basal insulin is usually continued (often at a reduced dose): clarify with the prescriber; hold mealtime insulin.
DKA drip: regular insulin IV; check K⁺ first (don't start if K⁺ <3.3: replace K⁺ first). Give SC basal insulin 1–2 h before stopping the drip.

Sick-day rules (type 1 and insulin users)

Keep taking basal insulin even if not eating; check glucose every 2–4 h and ketones if >240 mg/dL; drink fluids; call if vomiting, unable to keep fluids down, moderate/large ketones, or glucose staying high.

Morning highs

Dawn phenomenon: early-morning hormone surge raises glucose (2–3 AM glucose normal or high). Somogyi effect: night-time low followed by a rebound high (2–3 AM glucose low). Check a 2–3 AM glucose to tell them apart.

Non-Insulin Diabetes Medications

ADA Standards of Care 2025

Pharmacology

Updated: choose by the patient's other conditions For type 2 diabetes with heart disease, heart failure, or chronic kidney disease, an SGLT2 inhibitor and/or GLP-1 receptor agonist with proven benefit is recommended regardless of A1C or metformin use. For weight management, GLP-1 RAs or tirzepatide are preferred. Older guides that only list metformin, sulfonylureas and insulin are out of date.

Class	Examples	Key points
Biguanide	metformin	First-line for many. ↓ liver glucose output. No hypoglycemia alone. GI upset (take with meals; ER form helps); B12 deficiency. Not if eGFR <30. Hold around iodinated contrast in kidney impairment or unstable patients; restart after 48 h if kidney function is stable. Rare lactic acidosis.
SGLT2 inhibitors (-gliflozin)	empagliflozin, dapagliflozin, canagliflozin	Glucose leaves in urine. Protect heart and kidneys. Genital yeast infections, UTIs, dehydration, low BP, euglycemic DKA (DKA with near-normal glucose). Hold ~3 days before surgery and when acutely ill or not eating.
GLP-1 receptor agonists	semaglutide (injection or tablet), dulaglutide, liraglutide; tirzepatide (GIP/GLP-1)	Weekly or daily injection. Weight loss; heart benefit. Nausea, vomiting, diarrhea; pancreatitis (severe abdominal pain → stop, report); gallbladder disease. Slow stomach emptying: tell the anesthesia team (aspiration risk). Not with personal or family history of medullary thyroid cancer or MEN2. Oral semaglutide: empty stomach, ≤4 oz water, wait 30 min.
DPP-4 inhibitors (-gliptin)	sitagliptin, linagliptin	Modest effect; weight-neutral; low hypoglycemia. Joint pain, pancreatitis. Don't combine with a GLP-1 RA.
Sulfonylureas	glipizide, glimepiride, glyburide	Force insulin release: hypoglycemia (especially older adults: avoid glyburide), weight gain. Take with breakfast; don't skip meals.
Thiazolidinediones (-glitazone)	pioglitazone	Fluid retention, heart failure (avoid in HF), weight gain, fractures. Monitor liver tests.
Alpha-glucosidase inhibitors	acarbose	Take with the first bite; gas, bloating. Treat lows with glucose (table sugar won't be absorbed well).

Targets (individualized)

A1C	<7% for many adults (less strict, e.g. <8%, for frail or older adults)
Before meals	80–130 mg/dL
1–2 h after meals	<180 mg/dL
Hypoglycemia	Level 1 <70 · Level 2 <54 · Level 3: needs help from another person

Nursing points

Before contrast scans: check metformin and kidney function.
Before surgery: ask about SGLT2 inhibitors and GLP-1 RAs (both may need holding per protocol).
Teach foot care, eye exams yearly, kidney checks (urine albumin), BP and cholesterol control.
Watch for hypoglycemia when combining sulfonylureas or insulin with other agents.

Memory hook -gliflozin → glucose flows out in urine (think infections and fluid loss). -gliptin → gentle "tip" of glucose control. -glutide → glut-ted feeling: full stomach, nausea, weight loss.

Antibiotics I

Beta-lactams, vancomycin, aminoglycosides and fluoroquinolones

Pharmacology

Rules for every antibiotic

Ask about allergies and what the reaction was. Most people labelled "penicillin-allergic" can actually tolerate it when tested.
Cultures before the first dose, but never delay antibiotics in sepsis.
Take exactly as prescribed for the full prescribed course.
Report ≥3 watery stools in 24 h (C. diff): contact precautions, soap and water hand hygiene (alcohol gel doesn't kill spores).
Superinfection: thrush, vaginal yeast infection.

Birth control and antibiotics Updated

Most antibiotics (including penicillins, cephalosporins and tetracyclines) do not reduce hormonal contraceptive effectiveness (CDC). The important exception is rifampin/rifabutin: use a backup method. Vomiting or severe diarrhea can still reduce pill absorption.

Class	Examples	Key points
Penicillins	amoxicillin, amoxicillin-clavulanate, ampicillin, penicillin G, piperacillin-tazobactam	Rash, anaphylaxis, diarrhea. Observe after first dose. Penicillin G benzathine is IM only: never IV (can cause cardiac arrest).
Cephalosporins	cefazolin, cephalexin, ceftriaxone, cefepime	Cross-reaction with penicillin allergy is low (~1–2%); follow policy if the penicillin reaction was severe. Ceftriaxone: don't mix with calcium IV solutions (precipitates; especially newborns). Cefepime: confusion and seizures in kidney impairment.
Carbapenems	meropenem, imipenem, ertapenem	Broad spectrum. Seizure risk (imipenem). Lowers valproic acid levels: avoid together.
Vancomycin	IV; oral (for C. diff only)	MRSA, serious gram-positive infections. Infuse over ≥60 min (longer for bigger doses). Vancomycin infusion reaction (formerly "red man syndrome"): flushing, itching, rash of face/neck/upper body, low BP → slow or pause the infusion; antihistamine. Not a true allergy. Nephrotoxicity (worse with piperacillin-tazobactam), ototoxicity. Oral vancomycin isn't absorbed: it treats C. diff in the gut.
Aminoglycosides	gentamicin, tobramycin, amikacin; neomycin (oral)	Nephrotoxicity (creatinine, urine output) and ototoxicity (tinnitus, hearing loss, vertigo: may be permanent). Peak and trough levels. Can worsen myasthenia gravis. Neomycin isn't absorbed (bowel prep).
Fluoroquinolones (-floxacin)	ciprofloxacin, levofloxacin, moxifloxacin	Boxed warnings: tendon rupture (age >60, steroids, transplant), peripheral neuropathy, confusion and other CNS effects, worsening myasthenia gravis. Also aortic aneurysm, blood sugar swings, QT prolongation, photosensitivity. Separate from antacids, calcium, iron, zinc (2 h before or 6 h after). Avoid for simple UTI, sinusitis or bronchitis when other options exist.

Vancomycin monitoring Updated

For serious MRSA infections, current guidelines (2020) recommend dosing by AUC (area under the curve) 400–600, not trough levels alone. If your facility uses troughs, draw the trough just before the next dose.

Priority Anaphylaxis (hives, wheeze, throat tightness, low BP): stop the drug, call for help, IM epinephrine (anterolateral thigh) first, then airway, oxygen, fluids, antihistamine, steroid.

Antibiotics II, Antifungals and Antivirals

Including tuberculosis drugs

Pharmacology

Drug / class	Key points
Tetracyclines (doxycycline, minocycline)	Photosensitivity; pill esophagitis: full glass of water, stay upright 30 min, not at bedtime. Separate from antacids, calcium, iron. Avoid in pregnancy. Tooth staining in children <8, but short doxycycline courses (≤21 days) are safe at any age: it's the drug of choice for Rocky Mountain spotted fever. Updated
Macrolides (azithromycin, clarithromycin, erythromycin)	Atypical pneumonia, pertussis. QT prolongation, GI upset, liver injury. Clarithromycin and erythromycin interact with many drugs (statins, warfarin). They do not treat C. diff and can cause it.
Trimethoprim-sulfamethoxazole	UTI, MRSA skin infections, PJP prevention. Stop at first rash (Stevens-Johnson syndrome). ↑ K⁺, ↑ creatinine, crystals in urine (drink fluids), photosensitivity. ↑ INR with warfarin. Avoid near term and in infants <2 months.
Metronidazole	Anaerobes, bacterial vaginosis, trichomoniasis (treat partners), giardia. Metallic taste, dark urine, neuropathy with long use. Avoid alcohol during and for 3 days after (traditional advice). ↑ warfarin effect. No longer first-line for C. diff. Updated
Nitrofurantoin	Uncomplicated bladder infections only. Take with food; urine turns brown. Avoid if CrCl <30. Long-term: lung and liver reactions, neuropathy.
Clindamycin	Skin, anaerobes, dental. Highest C. diff risk. Full glass of water.
Linezolid	MRSA, VRE. Weak MAOI: serotonin syndrome with SSRIs; limit tyramine. Low platelets with long use.

C. diff treatment Updated

Fidaxomicin is preferred; oral vancomycin is an acceptable alternative (IDSA/SHEA 2021). Metronidazole only if neither is available. Stop the causing antibiotic if possible; contact precautions; soap and water; no antidiarrheal drugs unless ordered.

Antifungals

Nystatin: swish and swallow 4–5×/day; remove dentures first.
Fluconazole: QT, liver; ↑ warfarin and many drug levels.
Amphotericin B: fever, chills, rigors (premedicate as ordered), nephrotoxicity, low K⁺ and Mg²⁺. Lipid forms are less toxic.

Antivirals

Acyclovir / valacyclovir: herpes and shingles; hydrate (kidney crystals with IV); doesn't cure herpes.
Oseltamivir: influenza; most effective within 48 h of symptoms; also for prevention. (Baloxavir: single dose.)
HIV: treatment for everyone diagnosed, daily adherence; PrEP before exposure; PEP within 72 h after exposure.

Tuberculosis drugs (RIPE)

Rifampin	Orange-red urine, sweat and tears (stains soft contact lenses). Liver toxicity. Many interactions: weakens birth control pills, warfarin, HIV drugs: use backup contraception.
Isoniazid	Liver toxicity (report dark urine, jaundice, nausea; avoid alcohol; liver tests). Peripheral neuropathy: give pyridoxine (B6).
Pyrazinamide	Liver toxicity; ↑ uric acid (gout).
Ethambutol	Optic neuritis: check visual acuity and red-green color vision at baseline and regularly.

Ideally taken on an empty stomach, at the same time daily, often by directly observed therapy. Stopping early → drug resistance.

Antidepressants

SSRIs, SNRIs, bupropion, TCAs and MAOIs

Pharmacology

Class	Examples	Key points
SSRIs	sertraline, escitalopram, citalopram, fluoxetine, paroxetine	First-line for depression and anxiety. Nausea, sexual dysfunction, insomnia or sleepiness, low sodium (older adults), bleeding risk with NSAIDs/anticoagulants. Citalopram: QT (dose limits). Fluoxetine's long half-life means less withdrawal.
SNRIs	venlafaxine, duloxetine, desvenlafaxine	Depression, anxiety, nerve pain, fibromyalgia (duloxetine). Can raise BP; sweating; nausea. Bad withdrawal if stopped suddenly (venlafaxine).
NDRI	bupropion	Depression, smoking cessation. No sexual side effects or weight gain. Lowers seizure threshold: contraindicated in seizure disorders and in bulimia or anorexia (higher seizure risk).
Others	mirtazapine; trazodone	Mirtazapine: sedation, weight gain, take at bedtime. Trazodone: sedation (used for sleep), orthostasis, priapism (emergency).
Tricyclics (TCAs)	amitriptyline, nortriptyline, imipramine, clomipramine	Uses: depression, nerve pain, migraine prevention, bedwetting (imipramine), OCD (clomipramine). Anticholinergic effects, orthostasis, sedation. Deadly in overdose (wide QRS, dysrhythmias, seizures): give small supplies. Antidote: sodium bicarbonate.
MAOIs	phenelzine, tranylcypromine, isocarboxazid; selegiline patch	Used for treatment-resistant (and atypical) depression. Tyramine → hypertensive crisis. Many drug interactions.

Teach for all antidepressants

Full effect takes 4–6 weeks (some improvement may come in 1–2 weeks).
Don't stop suddenly (discontinuation symptoms): taper.
Boxed warning: increased suicidal thoughts in people under 25, especially early on or after dose changes. As energy returns before mood lifts, a person may act on a plan: monitor closely.
Avoid alcohol; no St. John's wort.

MAOI diet and drug rules

Avoid tyramine: aged cheese, cured, smoked or fermented meats (salami, pepperoni), tap or draft beer, soy sauce, sauerkraut, kimchi, fava beans, overripe or spoiled food, yeast extracts.

Hypertensive crisis: severe occipital headache, stiff neck, chest pain, palpitations, sweating.

Never combine with SSRIs, SNRIs, TCAs, meperidine, tramadol, dextromethorphan, linezolid, St. John's wort. Wait 14 days after stopping an MAOI (and 5 weeks after fluoxetine before starting one).

Serotonin syndrome

Cause: too much serotonin, usually from combinations (SSRIs, SNRIs, MAOIs, tramadol, linezolid, triptans, dextromethorphan, St. John's wort). Starts within hours.

Signs: agitation, confusion, sweating, high fever, fast heart rate, clonus and hyperreflexia, tremor, diarrhea. Action: stop the drugs, cool, benzodiazepines, cyproheptadine.

Memory hook: TCA anticholinergic effects "Can't see (blurred vision), can't pee (urinary retention), can't spit (dry mouth), can't poop (constipation)." Avoid in narrow-angle glaucoma, urinary retention, and older adults where possible.

Antipsychotics, Mood Stabilizers and Anxiolytics

Including ADHD medications

Pharmacology

First-generation (typical)

haloperidol, chlorpromazine, fluphenazine. Block dopamine (D2) receptors. Best for positive symptoms (hallucinations, delusions).

Higher risk of extrapyramidal symptoms (EPS), tardive dyskinesia, NMS.
Haloperidol: QT prolongation. Long-acting depot injections (decanoate) are given IM only.

Second-generation (atypical)

risperidone, olanzapine, quetiapine, aripiprazole, ziprasidone, lurasidone, clozapine. Block dopamine and serotonin receptors; treat positive and some negative symptoms.

Metabolic syndrome: weight gain, high glucose and lipids. Check weight, glucose, lipids at baseline and regularly.
Clozapine: severe neutropenia (monitor ANC), myocarditis (first weeks), seizures, severe constipation, drooling.
Ziprasidone and lurasidone: take with food.
New: xanomeline-trospium (2024) works without blocking dopamine. New

Movement and serious reactions

Acute dystonia	Hours–days: neck, eye (oculogyric crisis) or tongue spasm → benztropine or diphenhydramine IM/IV
Akathisia	Restlessness, can't sit still → lower dose, propranolol, benzodiazepine
Parkinsonism	Tremor, rigidity, shuffling → benztropine, amantadine
Tardive dyskinesia	Months–years: lip smacking, tongue movements, grimacing; may be permanent. Screen with AIMS. Treat with valbenazine or deutetrabenazine
Neuroleptic malignant syndrome	Emergency: high fever, "lead-pipe" rigidity, altered mental status, unstable BP and HR, ↑ CK. Stop the drug, cool, fluids, dantrolene or bromocriptine

Lithium

Level 0.6–1.2 mEq/L; toxic >1.5. Draw ~12 h after the last dose.
Keep sodium intake and fluids normal and steady (2–3 L/day). Low sodium or dehydration (vomiting, sweating, heat) → toxicity.
Raise levels: NSAIDs, ACE inhibitors/ARBs, thiazides.
Expected: fine tremor, thirst, frequent urination, weight gain. Long-term: hypothyroidism, kidney effects.
Toxicity: vomiting, diarrhea, coarse tremor, confusion, ataxia, seizures.
Teratogenic (heart defect): plan pregnancy with the prescriber.

Other mood stabilizers

Valproate: liver toxicity, pancreatitis, low platelets, weight gain; major birth defects (avoid in pregnancy).
Carbamazepine: SJS (HLA-B*1502 testing in Asian ancestry), low blood counts, low sodium; weakens birth control pills.
Lamotrigine: rash → SJS: must be increased slowly; report any rash.

Anxiolytics

Benzodiazepines (lorazepam, diazepam, alprazolam, chlordiazepoxide): sedation, falls (avoid in older adults where possible), dependence, withdrawal seizures if stopped suddenly. Boxed warning: with opioids → respiratory depression and death. Antidote: flumazenil. Used for alcohol withdrawal.
Buspirone: no dependence; takes 2–4 weeks; not for "as needed" use.

ADHD medications

Stimulants (methylphenidate, amphetamines): appetite and weight loss, insomnia (give early in the day), ↑ HR and BP, growth monitoring, misuse risk (controlled drug).
Non-stimulants: atomoxetine (suicidal thoughts warning), viloxazine, guanfacine, clonidine (sedation, low BP).

Pain Medications

Acetaminophen, NSAIDs, aspirin and opioids

Pharmacology

Compare

	Acetaminophen	NSAIDs	Aspirin	Opioids
Pain	✓	✓	✓	✓ (moderate–severe)
Fever	✓	✓	✓	–
Inflammation	– (none)	✓	✓	–
Antiplatelet	–	Temporary	✓ (irreversible)	–
Main danger	Liver	GI bleed, kidneys, heart	Bleeding; Reye's in children	Respiratory depression

Acetaminophen

Max 4 g/day in healthy adults (some labels and older adults: 3 g); ≤2 g/day with liver disease or regular alcohol use. It's the preferred pain reliever in cirrhosis at these lower doses.
Hidden acetaminophen in combination products (cold remedies, hydrocodone/APAP): add them up.
Overdose may look fine at first; liver failure in 2–3 days. Antidote: acetylcysteine.

NSAIDs (ibuprofen, naproxen, ketorolac, celecoxib)

Take with food; GI bleeding (black stools, coffee-ground vomit); a PPI may be added.
Kidney injury (especially with dehydration, ACEi/ARB + diuretic); ↑ BP; ↑ heart attack and stroke risk.
Ketorolac: max 5 days. Avoid NSAIDs from ~20 weeks of pregnancy unless prescribed.
Some people with asthma react (aspirin-exacerbated respiratory disease).

Opioids

morphine, hydromorphone, oxycodone, hydrocodone, fentanyl, methadone, tramadol.
Assess sedation before respirations: increasing sleepiness comes before respiratory depression (use a sedation scale such as POSS).
Naloxone: dilute and titrate IV in small doses (e.g., 0.04–0.4 mg) for over-sedation; 4 mg nasal in the community. Watch for return of sedation and for withdrawal and pain.
Constipation doesn't go away: start a stimulant laxative (senna) with the opioid; softener alone isn't enough.
Nausea, itching, urinary retention, orthostasis, confusion in older adults.
Morphine: active metabolites build up in kidney failure (hydromorphone or fentanyl preferred). Avoid meperidine (seizures).
Tramadol: seizures, serotonin syndrome.

Fentanyl patch

Only for opioid-tolerant patients with chronic pain. Not for acute pain.
Change every 72 h; remove the old patch; fold sticky sides together and dispose safely.
Heat increases absorption (fever, heating pads, hot tubs, saunas): overdose risk.
Keep away from children and pets (accidental exposure can kill).

New non-opioid option New

Suzetrigine (approved 2025) blocks pain signals in peripheral nerves (NaV1.8) for moderate-to-severe acute pain, without opioid sedation or addiction risk. Many interactions (CYP3A); avoid grapefruit.

Multimodal analgesia

Combine acetaminophen + NSAID + regional techniques + non-drug methods to reduce opioid needs.

Respiratory Medications

Inhalers, biologics, and cold and cough products

Pharmacology

Class	Examples	Key points
SABA (short-acting β2 agonist)	albuterol, levalbuterol	Quick relief. Tachycardia, tremor, nervousness, low K⁺. Needing it often = poor control.
LABA (long-acting)	salmeterol, formoterol, vilanterol	Never alone in asthma: always with an inhaled steroid. Formoterol works quickly, so ICS-formoterol can be used as a reliever.
Antimuscarinics	ipratropium (short); tiotropium, umeclidinium (long)	Dry mouth; caution in narrow-angle glaucoma and urinary retention (BPH). Keep spray out of eyes.
Inhaled corticosteroids	budesonide, fluticasone, beclomethasone	Control inflammation; not for quick relief. Thrush and hoarseness: spacer, rinse and spit.
ICS-formoterol	budesonide-formoterol	Preferred asthma reliever and maintenance-and-reliever therapy (GINA). Updated
Leukotriene modifier	montelukast	Oral, evening. Boxed warning: mood changes, agitation, nightmares, suicidal thoughts.
Biologics	omalizumab, mepolizumab, benralizumab, dupilumab, tezepelumab	Injections for severe asthma (some for COPD). Watch for anaphylaxis after doses (especially omalizumab).
Methylxanthine	theophylline	Narrow range; toxicity: tachycardia, vomiting, seizures. Caffeine adds to effects; many interactions.

Cold, allergy and cough products

First-generation antihistamines (diphenhydramine, chlorpheniramine): sedation, anticholinergic effects; avoid in older adults. Second-generation (loratadine, cetirizine) cause less drowsiness.
Decongestants (pseudoephedrine): raise BP and HR; avoid in uncontrolled hypertension. Nasal sprays (oxymetazoline): max ~3 days (rebound congestion). Oral phenylephrine is ineffective as a decongestant (FDA advisory committee 2023; FDA proposed removing it in 2024).
Dextromethorphan: serotonin syndrome with SSRIs/MAOIs.
Benzonatate: swallow whole (chewing numbs the throat; dangerous for young children).
No OTC cough and cold medicines for children under 4 (US labeling).

Systemic corticosteroids (short-term)

Prednisone, methylprednisolone for exacerbations.
Take in the morning with food.
High glucose (check in diabetes), insomnia, mood changes, fluid retention, increased appetite.
Longer courses: taper (see Endocrine).

Inhaler order

Bronchodilator first, then the steroid. Same medicine: wait 30–60 sec between puffs.

GI Medications

Acid, nausea, motility, bowels and the liver

Pharmacology

Drug	Key points
Antacids	Calcium carbonate (Tums): constipation. Magnesium hydroxide: diarrhea; avoid in kidney failure. Aluminum hydroxide: constipation. Take 1–3 h after meals and at bedtime; separate from other drugs by 1–2 h (they bind many drugs).
H2 blockers (-tidine)	famotidine. Before meals or at bedtime. Confusion in older adults (cimetidine has many interactions).
PPIs (-prazole)	omeprazole, pantoprazole. 30–60 min before breakfast. Long-term: C. diff, pneumonia, fractures, low Mg²⁺, low B12. Use the lowest dose for the shortest time needed.
Sucralfate	Coats ulcers. Empty stomach 1 h before meals; separate other meds by 2 h; constipation.
Misoprostol	Protects the stomach during NSAID use. Causes miscarriage: not in pregnancy (unless used obstetrically); reliable contraception.
Ondansetron	Antiemetic. QT prolongation, headache, constipation.
Metoclopramide	Dopamine blocker that speeds stomach emptying (prokinetic) and stops nausea. Boxed warning: tardive dyskinesia: avoid use >12 weeks. EPS, drowsiness. Avoid in Parkinson's and bowel obstruction.
Promethazine	Sedation, respiratory depression in children <2 (contraindicated). IV: severe tissue injury: deep IM preferred.
Lactulose	Hepatic encephalopathy: pulls ammonia into the gut. Goal 2–3 soft stools a day; watch K⁺ and fluid. Often combined with rifaximin.
Loperamide	Not for bloody diarrhea, fever, or C. diff. High doses → dangerous heart rhythms.

Laxatives

Bulk-forming (psyllium)	With a full glass of water; 1–3 days
Osmotic (polyethylene glycol, lactulose)	1–3 days; bowel prep (large-volume PEG)
Stimulant (senna, bisacodyl)	6–12 h; for opioid constipation. Don't crush bisacodyl or take with milk/antacids
Softener (docusate)	Weak on its own

H. pylori

Combination therapy for 14 days: a PPI + antibiotics (often bismuth quadruple therapy: PPI, bismuth, tetracycline, metronidazole). Bismuth turns stools and tongue black (harmless). Test for cure afterwards.

IBD

Aminosalicylates (mesalamine), steroids, immunomodulators, and biologics (infliximab, adalimumab, vedolizumab, ustekinumab): screen for TB and hepatitis B before biologics; no live vaccines.

Endocrine and Musculoskeletal Drugs

Thyroid, corticosteroids, gout and bone

Pharmacology

Levothyroxine

Same time daily on an empty stomach, 30–60 min before breakfast, with water.
Separate from calcium, iron, antacids and binders by 4 h. Long-term PPIs can lower absorption (check TSH).
TSH is rechecked after 6–8 weeks; dose changes take that long to show.
Too much = hyperthyroid signs: palpitations, tachycardia, insomnia, weight loss, heat intolerance.
Older adults and heart disease: start low, go slow. Dose usually increases in pregnancy. Lifelong.

Antithyroid drugs

Methimazole is first-line for hyperthyroidism.
PTU is used in the first trimester of pregnancy and in thyroid storm. It carries a boxed warning for severe liver injury.
Both cross the placenta. PTU is preferred in the first trimester because methimazole can cause birth defects then; switching to methimazole afterwards may be considered (PTU liver risk).
Both: agranulocytosis: report sore throat and fever immediately (check WBC).
Others: beta blockers for symptoms; iodine before surgery; radioactive iodine (not in pregnancy or breastfeeding; distance and hygiene precautions).

Long-term corticosteroids (prednisone, hydrocortisone, dexamethasone)

↑ glucose, ↑ BP, fluid retention, weight gain, moon face
Infection risk and masked signs of infection
Osteoporosis (calcium, vitamin D, bone density), cataracts, glaucoma
Stomach irritation (take with food), thin skin, poor wound healing
Mood changes, insomnia

Never stop suddenly after more than ~2–3 weeks: taper (risk of adrenal crisis).
Extra "stress dosing" may be needed during illness or surgery: per prescriber.
Take in the morning (mimics the body's rhythm).
Avoid live vaccines on high doses.

Gout

Acute flare: NSAIDs, colchicine (diarrhea is a toxicity sign; lower doses now used), or steroids.
Prevention (lower uric acid): allopurinol (first-line), febuxostat. Allopurinol can be started during a flare with anti-inflammatory cover. Stop and report any rash (SJS); HLA-B*5801 testing for some ancestries.
Fluids 2–3 L/day; limit alcohol (especially beer), organ meats, shellfish, sugary drinks.

Osteoporosis

Bisphosphonates (alendronate, risedronate): first thing in the morning with a full glass of plain water, empty stomach, stay upright 30 min before food or other drugs (esophagitis). Rare jaw osteonecrosis (dental check) and thigh fractures.
Denosumab: injection every 6 months; low calcium; don't stop without a plan (rebound spine fractures).
Anabolic: teriparatide, abaloparatide, romosozumab (heart risk).
Calcium + vitamin D; weight-bearing exercise; fall prevention.

Neurologic Medications

Seizures, Parkinson's, myasthenia gravis and dementia

Pharmacology

Antiseizure medications

Phenytoin	Level 10–20 mcg/mL. Gum overgrowth (oral hygiene), ataxia, nystagmus (toxicity), rash. IV: saline only, max 50 mg/min, in-line filter; extravasation injury. Many interactions. Fosphenytoin is safer IV
Levetiracetam	Few interactions; mood changes, irritability
Valproate	Liver, pancreas, platelets; birth defects
Carbamazepine	Low sodium, low blood counts, SJS; induces enzymes (weakens birth control)
Lamotrigine	Rash/SJS: slow dose increases

Teach: don't stop suddenly (seizures); medical ID; no driving until cleared; folic acid before pregnancy. Status epilepticus: IV lorazepam (or IM midazolam) first, then a second-line IV drug (levetiracetam, fosphenytoin, valproate).

Parkinson's disease

Carbidopa-levodopa: most effective. Nausea, orthostatic hypotension, dyskinesias, "wearing-off". High-protein meals reduce absorption: spread protein through the day. Dark urine and sweat. Never stop suddenly (NMS-like reaction).
Dopamine agonists (pramipexole, ropinirole): sleep attacks, impulse-control problems (gambling, shopping).
MAO-B inhibitors (selegiline, rasagiline); amantadine; anticholinergics (avoid in older adults).
Avoid: metoclopramide, haloperidol (worsen symptoms).

Myasthenia gravis

Pyridostigmine: take on time, 30–60 min before meals (helps chewing and swallowing).
Myasthenic crisis (too little drug or illness) vs. cholinergic crisis (too much: SLUDGE, bradycardia, small pupils). Both cause weakness and respiratory failure: airway first; atropine for cholinergic crisis.
Newer: complement inhibitors and FcRn blockers (e.g., efgartigimod).
Avoid drugs that worsen MG: aminoglycosides, fluoroquinolones, magnesium, some beta blockers.

Alzheimer's disease

Cholinesterase inhibitors (donepezil, rivastigmine patch, galantamine): nausea, bradycardia, syncope; donepezil at bedtime (vivid dreams → morning).
Memantine: moderate–severe disease; dizziness.
Anti-amyloid antibodies for early disease: donanemab (IV every 4 weeks), lecanemab (IV, or weekly subcutaneous autoinjector). MRI monitoring for ARIA (brain swelling or bleeding): headache, confusion, vision change. APOE ε4 carriers are at higher risk. New

Memory hook: cholinergic excess = SLUDGE Salivation · Lacrimation · Urination · Defecation · GI upset · Emesis. Plus bradycardia, bronchospasm, small pupils. Opposite of the anticholinergic "can't see, can't pee" picture.

High-Alert Medications, Electrolytes and Blood

Where small mistakes cause big harm

Pharmacology

High-alert medications (ISMP)

Insulin · heparin and other anticoagulants · opioids · IV potassium chloride concentrate · magnesium sulfate · neuromuscular blockers · chemotherapy · hypertonic saline · sedation agents · oxytocin · TPN.

Independent double checks per policy; smart pumps with dose limits.
Avoid error-prone abbreviations: write "units" (not U or IU), "daily" (not QD), "every other day" (not QOD), "discharge" or "discontinue" (not D/C), "at bedtime" (not HS). No trailing zero (1 mg, not 1.0 mg); always a leading zero (0.5 mg, not .5 mg).

IV potassium: rules

Never IV push or IM. Always diluted, on a pump.
Usual max rate 10 mEq/h peripherally (higher only via central line with cardiac monitoring, per policy).
Check urine output (≥30 mL/h) and kidney function first.
Burns at the IV site: check for infiltration.
Oral K⁺: with food and a full glass of water.

Electrolyte quick reference

Electrolyte	Normal	Too low	Too high
Potassium	3.5–5.0 mEq/L	Weakness, cramps, flat T waves, U waves, dysrhythmias	Peaked T waves, weakness, dysrhythmias → calcium gluconate, insulin + dextrose, albuterol, binders, dialysis
Sodium	135–145 mEq/L	Confusion, headache, seizures	Thirst, confusion, seizures
Calcium	8.5–10.5 mg/dL	Trousseau's and Chvostek's signs, tetany, long QT	Weakness, constipation, kidney stones, confusion
Magnesium	1.5–2.5 mg/dL	Tremors, hyperreflexia, torsades	Loss of reflexes, respiratory depression
Phosphate	2.5–4.5 mg/dL	Weakness (refeeding syndrome)	Itching; low calcium (kidney failure)

Correct chronic low sodium slowly (generally ≤8–10 mEq/L in 24 h) to avoid osmotic demyelination. Ranges vary slightly by lab.

Blood transfusion

Consent; two-person bedside check of patient ID and blood product.
Baseline vital signs; normal saline only in the line; blood filter tubing. Adults: 18–20 G preferred (20–22 G acceptable for routine transfusion); 22–24 G for children.
Stay with the patient for the first 15 min; go slowly at first.
Finish each unit within 4 hours of leaving the blood bank.

Transfusion reaction Fever, chills, back pain, hives, wheeze, low BP, dark urine, dyspnea:
1. Stop the transfusion. 2. Keep the IV open with normal saline through new tubing. 3. Vital signs; stay with the patient. 4. Notify provider and blood bank. 5. Send the bag and tubing back; collect blood and urine samples per policy.
Watch for fluid overload (TACO) in heart failure and older adults.

Infection Control and Isolation

CDC standard and transmission-based precautions

Fundamentals

Standard precautions: every patient

Hand hygiene: alcohol-based rub for most care; soap and water when hands are visibly soiled, and for C. diff or norovirus (alcohol doesn't kill spores).
PPE based on expected exposure to blood or body fluids.
Respiratory hygiene and cough etiquette; safe injection practices; never recap needles.
Clean and disinfect equipment between patients.

PPE order

Put on (don)

Gown
Mask or respirator
Goggles or face shield
Gloves

Take off (doff)

Gloves
Goggles or face shield
Gown
Mask or respirator (outside the room for airborne)
Hand hygiene

Gloves come off first because they're the most contaminated. Perform hand hygiene any time hands become contaminated during removal.

Transmission-based precautions

Type	Examples	Room and PPE
Contact	MRSA, VRE, other multidrug-resistant organisms, RSV, scabies, lice, draining wounds, impetigo	Private room or cohort; gown and gloves; dedicated equipment (stethoscope, BP cuff)
Contact enteric ("contact plus")	C. difficile, norovirus, rotavirus, infectious diarrhea	Gown and gloves; soap and water hand hygiene; bleach-based (sporicidal) cleaning
Droplet	Influenza, pertussis, mumps, rubella, N. meningitidis and Hib (first 24 h of antibiotics), adenovirus, Mycoplasma pneumonia, group A strep pharyngitis/scarlet fever (first 24 h)	Private room (or ≥3 ft spacing + curtain); surgical mask on entering; patient wears a mask during transport
Airborne	TB, measles, chickenpox, shingles that is disseminated or in an immunocompromised patient (airborne + contact)	Negative-pressure room (AIIR), door closed; fit-tested N95 or higher; patient wears a surgical mask during transport

COVID-19: CDC recommends an N95, eye protection, gown and gloves. Localized shingles in a patient with a normal immune system, fully covered: standard precautions. Staff who aren't immune to measles or chickenpox shouldn't care for those patients.

Neutropenic (protective) precautions

ANC = WBC × (% neutrophils + % bands) ÷ 100. <500/mm³ = severe neutropenia.
Private room; strict hand hygiene; no sick visitors; mask for the patient outside the room.
No fresh flowers or standing water; safe food handling (well-cooked meat, washed produce).
Avoid rectal temps, suppositories and enemas.
Fever ≥100.4°F (38°C) = emergency: cultures and antibiotics within 1 hour.

Memory hooks Airborne = "MTV": Measles, TB, Varicella.

Droplet: think of anything spread by a sneeze or cough at close range: flu, pertussis, mumps, rubella, meningococcal.

Contact: anything you could pick up by touch: resistant bacteria, diarrhea, skin infestations, wounds.

Sterile technique

A sterile field is only sterile if you can see it: keep it above waist level and in view; 1-inch border is non-sterile; don't reach across it; any doubt = contaminated; sterile touches sterile only; open the first flap of a package away from you.

Patient Safety

Falls, restraints, fire, seizures and medication safety

Fundamentals

Fall prevention

Screen on admission and every shift (e.g., Morse Fall Scale) and after any change.
Bed in lowest position, wheels locked, call light and belongings within reach.
Non-skid footwear; clear pathways; night light.
Scheduled toileting (most falls happen on the way to the bathroom).
Bed or chair alarms for high-risk patients; review sedating drugs.
Side rails used to keep a patient from getting out of bed (e.g., all four up) count as a restraint and raise entrapment and fall-injury risk.

Restraints (CMS rules)

Last resort, after less restrictive options fail; least restrictive type; never for staff convenience or discipline.
Needs a prescriber's order, never "PRN".
Violent or self-destructive behavior: order lasts up to 4 h (adults), 2 h (ages 9–17), 1 h (under 9); face-to-face evaluation within 1 hour.
Non-violent (medical) restraints: renewed per hospital policy (commonly each calendar day).
Monitor frequently per policy (often every 15 min); at least every 2 h: release, range of motion, skin, circulation, toileting, fluids.
Tie to the bed frame (not the side rail) with a quick-release knot; two fingers fit under the restraint.

Fire

RACE

Rescue patients in danger · Alarm (pull it, call) · Confine (close doors) · Extinguish or Evacuate.

PASS (extinguisher)

Pull the pin · Aim at the base · Squeeze · Sweep side to side.

Evacuate horizontally first (to another unit on the same floor), then vertically. Ambulatory patients first, then wheelchair, then bed-bound (unless directed otherwise).

Seizure precautions

Padded side rails, bed low, suction and oxygen at the bedside, IV access as ordered.
During: stay, time it, turn on the side, protect the head, loosen clothing. Never restrain or put anything in the mouth.
After: airway, suction, side-lying, neuro checks, reorient; document onset, duration, movements, aftermath.
Seizure >5 min = status epilepticus: emergency.

Medication safety

Rights of medication administration

Right patient (2 identifiers: name + date of birth, not room number), drug, dose, route, time, documentation, plus right reason, response, and the patient's right to refuse.

Three checks

When pulling the drug, when preparing it, and at the bedside before giving it.

Don't

Give a drug someone else prepared.
Leave meds at the bedside.
Crush extended-release (ER, XR, SR, LA), enteric-coated, or sublingual drugs.
Use error-prone abbreviations (U, IU, QD, QOD, D/C, HS, trailing zeros).

If an error happens: assess the patient first, notify the prescriber, complete an incident report (not mentioned in the chart).

Older adults: Beers Criteria highlights

Avoid where possible: first-generation antihistamines (diphenhydramine), benzodiazepines and "Z-drugs" (zolpidem), anticholinergics, long-acting sulfonylureas (glyburide), muscle relaxants, routine NSAIDs, meperidine.

Priority Patient found on the floor: assess first (ABCs, injuries, neuro check), don't move them until assessed, get help, notify, document facts only.

Vital Signs and Physical Assessment

Normal findings and what the abnormal ones mean

Fundamentals

Adult vital signs

Temperature	~97.8–99.1°F (36.5–37.3°C) oral; fever ≥100.4°F (38°C)
Pulse	60–100/min
Respirations	12–20/min
Blood pressure	<120/<80 mmHg
SpO₂	95–100% (most adults)

Pulse pressure = systolic − diastolic (normal ~40). MAP = (SBP + 2 × DBP) ÷ 3; ≥65 needed for organ perfusion. Count irregular pulses for a full minute; apical pulse at the 5th intercostal space, midclavicular line.

Grading scales

Pulses		Pitting edema
0	Absent	1+	2 mm, rebounds quickly
1+	Weak, thready	2+	4 mm, ~10–15 sec
2+	Normal	3+	6 mm, >1 min
3+	Bounding	4+	8 mm, 2–5 min

Capillary refill normal <2–3 sec. Skin turgor is unreliable in older adults (check the sternum or forehead, or rely on other signs).

Lung sounds

Vesicular	Soft, low; most of the lungs; inspiration > expiration
Bronchial	Loud, high; over the trachea; expiration > inspiration. Abnormal over the lung fields → consolidation
Crackles	Popping (fine or coarse), usually inspiration: fluid in alveoli (HF, pneumonia, atelectasis)
Wheezes	Musical, high-pitched: narrowed airways (asthma, COPD)
Rhonchi	Low snoring sound: secretions in large airways; may clear with coughing
Stridor	High-pitched, inspiratory, upper-airway obstruction: emergency
Friction rub	Grating, with breathing: pleural inflammation

Heart sounds

S1 ("lub"): mitral and tricuspid valves close; loudest at the apex.
S2 ("dub"): aortic and pulmonic valves close; loudest at the base.
S3: after S2; volume overload, heart failure (can be normal in children, young athletes, pregnancy).
S4: before S1; stiff ventricle (hypertension, MI).
Murmurs graded 1–6 (4+ has a palpable thrill).

Listening points: "APE To Man"

Aortic: 2nd ICS right sternal border · Pulmonic: 2nd ICS left · Erb's point: 3rd ICS left · Tricuspid: 4th–5th ICS left lower sternal border · Mitral: 5th ICS midclavicular (apex).

Abdomen

Order: inspect, auscultate, percuss, palpate (palpating first changes bowel sounds). Normal bowel sounds ~5–30/min. Listen up to 5 min in each quadrant before calling them absent. Palpate tender areas last.

Pain assessment (OLDCARTS)

Onset · Location · Duration · Character · Aggravating factors · Relieving factors · Timing · Severity (0–10). Reassess after interventions (e.g., 30–60 min after oral, 15–30 min after IV). Pain is what the patient says it is.

Common Lab Values

Adult reference ranges (each lab's own ranges vary slightly: use yours)

Fundamentals

Complete blood count

WBC	5,000–10,000/mm³
RBC	Men 4.7–6.1 · Women 4.2–5.4 million/mm³
Hemoglobin	Men 14–18 · Women 12–16 g/dL
Hematocrit	Men 42–52% · Women 37–47%
Platelets	150,000–400,000/mm³ (bleeding risk <50,000; spontaneous bleeding <20,000)
ANC	>1,500 normal; <500 severe neutropenia

Basic metabolic panel

Sodium	135–145 mEq/L
Potassium	3.5–5.0 mEq/L
Chloride	98–106 mEq/L
Bicarbonate (CO₂)	22–26 mEq/L (some labs 23–29)
BUN	10–20 mg/dL
Creatinine	~0.6–1.2 mg/dL
Glucose (fasting)	70–99 mg/dL
Calcium	9.0–10.5 mg/dL (some labs 8.5–10.5)

Other electrolytes and kidney

Magnesium	1.5–2.5 mg/dL (1.3–2.1 mEq/L)
Phosphorus	2.5–4.5 mg/dL
eGFR	≥90 mL/min/1.73 m² normal; <60 for 3 months = CKD
Serum osmolality	275–295 mOsm/kg
Urine specific gravity	1.005–1.030 (high = concentrated)
Uric acid	Men 4.0–8.5 · Women 2.7–7.3 mg/dL

Coagulation

PT	11–12.5 sec
INR	0.8–1.1 (warfarin goal usually 2–3)
aPTT	30–40 sec
Fibrinogen	200–400 mg/dL (low in DIC)
D-dimer	Below lab cut-off (high = clot breakdown; non-specific)

Liver and pancreas

ALT / AST	~4–36 / 0–35 U/L (ranges vary)
Alkaline phosphatase	30–120 U/L
Total bilirubin	0.3–1.0 mg/dL
Albumin	3.5–5.0 g/dL
Ammonia	Lab-specific (roughly 15–45 mcg/dL); high in hepatic encephalopathy
Lipase	Lab-specific; ≥3× upper limit supports pancreatitis

Others

Hemoglobin A1C	<5.7% normal · 5.7–6.4% prediabetes · ≥6.5% diabetes
TSH	~0.4–4.0 mIU/L
Lactate	<2 mmol/L (≥4 in sepsis = shock risk)
BNP	<100 pg/mL
Troponin (high-sensitivity)	Below the lab's 99th percentile; rising = heart injury
CRP / ESR	Markers of inflammation

Priority: report right away K⁺ <3.0 or >5.5–6.0 · Na⁺ <125 or >155 · glucose <70 or very high · platelets <50,000 · ANC <500 · Hgb <7 · INR well above goal · positive blood cultures · troponin rising · lactate ≥4. Facilities set their own "critical value" lists.

IV Fluids and Vascular Access

Choosing fluids, spotting complications, and central-line care

Fundamentals

IV fluid types

Type	Examples	Use	Caution
Isotonic (stays in the vessels)	0.9% NaCl, lactated Ringer's, Plasma-Lyte	Volume replacement, shock, blood transfusion (NS only), resuscitation	Fluid overload in HF and kidney failure
Hypotonic (moves into cells)	0.45% NaCl; D5W once the sugar is used	Cellular dehydration, hypernatremia	Avoid in ↑ICP, burns, trauma (worsens swelling and third-spacing)
Hypertonic (pulls fluid out of cells)	3% NaCl, D10W, D5NS, D5½NS, D5LR	Severe hyponatremia, cerebral edema (3% saline)	Fluid overload; 3% saline via pump with frequent Na⁺ checks

D5W is not used for resuscitation or in brain injury. Hypertonic saline correction must be slow (generally ≤8–10 mEq/L in 24 h).

IV complications

Problem	Signs	Action
Infiltration	Cool, pale, swollen, tight skin; slow flow	Stop, remove, elevate; warm or cold compress per fluid; restart elsewhere
Extravasation (vesicant)	As above + pain, blistering, tissue damage	Stop and disconnect; aspirate through the catheter; antidote per protocol (e.g., phentolamine for norepinephrine); then remove; elevate; notify
Phlebitis	Red, warm, tender, cord-like vein	Stop, remove, warm compress, restart in the other arm
Fluid overload	Crackles, dyspnea, JVD, ↑ BP, edema	Slow the IV, high Fowler's, oxygen, notify (diuretic)
Air embolism	Sudden dyspnea, chest pain, hypotension	Clamp the line; left side, head down (Trendelenburg); oxygen; call for help
Local infection	Redness, drainage at site, fever	Remove; culture per order

Central lines (CLABSI prevention)

Insertion: hand hygiene, maximal sterile barriers, chlorhexidine-alcohol skin prep; avoid the femoral site when possible.
Scrub the hub 5–15 sec before every access; needleless connectors.
Transparent dressing changed every 7 days (gauze every 2 days) or sooner if damp, loose or soiled.
Flush with a 10 mL (or larger) syringe, push-pause technique.
Review every day whether the line is still needed.
Removal: patient flat or slightly head-down; Valsalva (or breath-hold) during removal; occlusive dressing.
PICC: no BP or blood draws on that arm.

Parenteral nutrition (TPN)

Central line (high dextrose); dedicated lumen; never add drugs.
Filter per policy; change tubing every 24 h.
Monitor glucose often (hyperglycemia); weigh daily; electrolytes.
Don't stop suddenly: if the bag is late or runs out, hang D10W at the same rate (prevents rebound hypoglycemia).
Refeeding syndrome in malnourished patients: low phosphate, K⁺ and Mg²⁺: start slowly.

Pressure Injuries and Wound Care

NPIAP staging, Braden scale, and wound healing

Fundamentals

Pressure injury stages (NPIAP)

Stage 1	Intact skin with non-blanchable redness (may look different in darker skin: check warmth, firmness, pain)
Stage 2	Partial-thickness loss with exposed dermis: shallow pink-red wound bed or intact/ruptured serum blister. No slough
Stage 3	Full-thickness skin loss; fat may be visible; slough or eschar may be present; undermining or tunneling possible. No bone, tendon or muscle
Stage 4	Full-thickness skin and tissue loss with exposed fascia, muscle, tendon, ligament, cartilage or bone
Unstageable	Base hidden by slough or eschar. Leave stable, dry eschar on heels in place
Deep tissue pressure injury	Intact or non-intact skin with persistent non-blanchable deep red, maroon or purple color, or a blood-filled blister

Also: medical device–related injuries (staged) and mucosal membrane injuries (not staged). They're called "stages", not "types". Don't reverse-stage: a healing stage 3 stays "healing stage 3".

Braden scale

Six areas: sensory perception, moisture, activity, mobility, nutrition (each 1–4), friction and shear (1–3). Total 6–23; lower score = higher risk.

15–18	Mild risk
13–14	Moderate risk
10–12	High risk
≤9	Very high risk

Prevention

Reposition regularly (commonly every 2 h in bed), 30° side-lying tilt.
HOB ≤30° unless contraindicated (reduces shear); lift, don't drag.
Float heels; pressure-redistributing mattress; no donut cushions.
Keep skin clean and dry; barrier cream for incontinence.
Don't massage red bony areas.
Protein and calories (dietitian); hydration.

Wound basics

Healing: primary intention (edges closed), secondary (left open, granulates), tertiary (delayed closure).
Drainage: serous (clear), sanguineous (bloody), serosanguineous (pink), purulent (pus: infection).
Infection: redness, warmth, swelling, pain, odor, purulent drainage, fever, usually days 3–7.
Wound vac (negative pressure): keep the seal; don't leave it off for long periods (follow policy); stop and notify for bright red bleeding.

Dehiscence and evisceration Dehiscence: wound edges separate. Evisceration: organs protrude (emergency).
Stay with the patient; call for help; cover with sterile gauze moistened with sterile saline; low Fowler's with knees bent; nothing by mouth; monitor for shock.

Nutrition and Feeding

Diets, dysphagia, and enteral tube feeding

Fundamentals

Texture diets

Clear liquid	Water, clear broth, apple juice, gelatin, popsicles, tea or coffee without milk
Full liquid	Clear liquids + milk, pudding, yogurt, ice cream, cream soups, strained cereals
Pureed / mechanical soft	For chewing or swallowing problems

IDDSI levels Updated

Drinks: 0 thin · 1 slightly thick · 2 mildly thick · 3 moderately thick. Foods: 3 liquidized · 4 pureed (also extremely thick drinks) · 5 minced and moist · 6 soft and bite-sized · 7 regular. These replace the old "nectar-thick" and "honey-thick" terms.

Therapeutic diets

Cardiac	Low sodium, low saturated fat
Renal (CKD)	Limit sodium, potassium, phosphorus; protein as prescribed; fluid limit on dialysis
Diabetic	Consistent carbohydrate
Low residue	Flare of IBD, before colonoscopy
High fiber	Constipation, diverticulosis
Low purine	Gout: limit organ meats, shellfish, beer
Gluten-free	Celiac: no wheat, barley, rye ("BROW": also avoid oats unless certified gluten-free)

Dysphagia and aspiration precautions

Swallow screen before food, fluid or oral meds after stroke or extubation.
Sit upright at 90°; stay up 30 min after meals.
Chin tuck when swallowing; small bites; no rushing; check for pocketing.
Thickened liquids at the ordered IDDSI level; straws only if allowed.
Signs of aspiration: coughing, wet voice, drooling, ↓ SpO₂.

Enteral (tube) feeding

X-ray confirms placement of a blindly placed tube before first use. Then mark the tube at the exit point and check length each time; aspirate pH ≤5 supports gastric placement. Auscultating air is not reliable.
HOB ≥30–45° during feeding (always, for continuous feeds).
Flush with water (often 30 mL) every 4 h and before and after each medication. Give meds separately; use liquids; never crush ER or enteric-coated drugs.
Gastric residual checks are no longer routine in many ICUs: follow policy.
Diarrhea, cramping: check rate, formula, medications (sorbitol), C. diff.

Nutrition markers

BMI = kg ÷ m². <18.5 underweight · 18.5–24.9 healthy · 25–29.9 overweight · ≥30 obesity. Albumin and prealbumin fall with inflammation, so they're poor nutrition markers on their own; use weight change and intake.

Priority Coughing or respiratory distress during a tube feeding → stop the feeding, keep the head up, suction if needed, check SpO₂, notify.

Elimination, Catheters and Ostomies

Urinary catheters, CAUTI prevention, enemas and ostomy care

Fundamentals

Urinary catheter insertion

Sterile technique; female: dorsal recumbent; male: hold penis upright at ~60–90°.
Female: if the catheter enters the vagina, leave it as a landmark and insert a new sterile catheter into the urethra.
Inflate the balloon only after urine returns (advance a little further first, to the hilt in males).
Secure to the thigh (or abdomen for males) to prevent pulling.
Bladder scanner: post-void residual >~150–200 mL suggests retention (follow protocol).

CAUTI prevention

Insert only when truly needed (not for incontinence or convenience); remove as soon as possible (nurse-driven removal protocols).
Closed drainage system; bag below the bladder and off the floor; no dependent loops.
Daily perineal and meatal care with soap and water.
Don't routinely irrigate or change the catheter; collect specimens from the sampling port with sterile technique.
After removal: should void within ~6–8 h; measure the first voids.

Enemas and bowel care

Left side-lying (Sims') position: follows the shape of the colon.
Adult: insert the lubricated tip 3–4 in (7.5–10 cm); bag no higher than ~18 in above the anus.
Cramping: lower the bag or pause; have the patient breathe slowly.
"Enemas until clear": usually a maximum of 3 (follow orders).
Digital removal of impaction can trigger a vagal response: watch for bradycardia.

Specimens

Clean-catch midstream urine: clean front to back; start voiding, then collect midstream.
24-hour urine: discard the first void, then collect every void, ending with a final void at the same time the next day. Keep on ice or refrigerated as instructed. If a void is missed, restart.
Stool for occult blood (FIT test is preferred: no diet restriction).

Ostomies

Stoma check

Normal: moist, pink to beefy red, slightly raised. Swelling decreases over 6–8 weeks.
Pale: anemia. Dusky, purple, brown or black: poor blood supply: report immediately.
Mild bleeding on cleaning is normal (it's very vascular).

Pouching

Cut the opening ~⅛ in (2–3 mm) larger than the stoma.
Empty when ⅓–½ full; change the wafer every 3–7 days or if leaking.
Skin barrier on clean, dry skin; check for irritation.

	Ileostomy	Colostomy (descending/sigmoid)
Output	Liquid, continuous, enzyme-rich (skin damage)	Formed stool; may become regular
Risks	Dehydration, low Na⁺ and K⁺; food blockage	Constipation
Teach	Fluids 2–3 L/day; chew well; limit high-fiber foods that can block (nuts, popcorn, corn); ER tablets may pass whole	Odor control; some can irrigate to regulate

Body image: encourage looking at and touching the stoma; ostomy nurse (WOC nurse) referral; support groups.

Perioperative Care

Before, during and after surgery

Fundamentals

Before surgery

Informed consent: the surgeon explains risks, benefits and alternatives; the nurse witnesses the signature and confirms the patient understands. Get it before sedating medications. Use a qualified interpreter if needed.
Fasting (ASA): clear liquids up to 2 h before; breast milk 4 h; light meal, formula or non-human milk 6 h; fatty or fried food, meat ≥8 h.
Remove jewelry, dentures, nail polish as policy requires; void.
Check labs, allergies, H&P, pregnancy test as indicated, site marking by the surgeon.

Medications to ask about

Anticoagulants and antiplatelets: hold per the surgeon's plan (e.g., warfarin ~5 days; DOACs 1–3+ days depending on drug and kidney function). Never stop after a recent stent without the cardiologist.
SGLT2 inhibitors: hold ~3 days (ertugliflozin 4).
GLP-1 receptor agonists: most patients continue them (2024 multisociety guidance); higher-risk patients (dose recently increased, nausea, vomiting, bloating) may need a 24-h clear-liquid diet before surgery. Tell the anesthesia team (aspiration risk).
Insulin: basal dose usually reduced, not skipped; glucose checks.
Herbal supplements (garlic, ginkgo, ginseng, St. John's wort): stop ~1–2 weeks before.
Beta blockers usually continue; ACE inhibitors/ARBs often held the morning of surgery.

In the operating room

Universal Protocol: pre-procedure verification, site marking, and a time-out with the whole team before the incision.
Counts of sponges, sharps and instruments.
Positioning: pad pressure points; avoid nerve injury.
Circulating nurse (non-sterile) vs scrub nurse (sterile).

Malignant hyperthermia

Triggered by volatile anesthetic gases and succinylcholine. Earliest sign: unexplained rise in end-tidal CO₂, then tachycardia, muscle (jaw) rigidity, hyperkalemia; high fever is a late sign. Stop triggers, dantrolene IV, cool, treat high K⁺.

After surgery (PACU and unit)

Airway first (jaw thrust if obstructed), breathing, circulation; vital signs often every 15 min at first.
Pain and nausea control; level of consciousness; dressing and drains.
Should void within ~6–8 h; bladder scan if not.
Turn, cough, deep breathe; incentive spirometer 10 times/hour while awake.
Early ambulation; SCDs and anticoagulant prophylaxis as ordered.
Diet advanced as bowel function returns (flatus, bowel sounds).

Post-op complications: typical timing

When	Complication	Clues
First hours	Hemorrhage, hypovolemic shock	Tachycardia, ↓ BP, restlessness, saturated dressing, bleeding under the patient
Days 1–2	Atelectasis, pneumonia	↓ breath sounds, crackles, fever, ↓ SpO₂
Days 1–5	Paralytic ileus, urinary retention, UTI	Distension, no bowel sounds or flatus; not voiding; burning
Days 3–7	Wound infection	Red, warm, swollen, drainage, fever
Days 5–8	Dehiscence / evisceration	"Something gave way"; serosanguineous drainage gush
Any time (often day 5+)	DVT / PE	Calf swelling; sudden dyspnea and chest pain

Memory hook: post-op fever "5 Ws" Wind (lungs, days 1–2) · Water (urinary tract, days 3–5) · Wound (days 3–7) · Walking (DVT/PE, day 5+) · Wonder drugs (drug fever, any time).

Prioritization and Delegation

Who to see first, and who can do what

Fundamentals

Who do I see first?

Airway, Breathing, Circulation (in cardiac arrest: compressions first, C-A-B).
Acute and unexpected before chronic and expected.
Unstable before stable; actual problems before potential ones.
Maslow: physiological needs → safety → love and belonging → esteem → self-actualization.
Nursing process: assess before acting (unless the situation clearly needs immediate action).

Ask: "What will kill or harm this patient soonest?" A change in level of consciousness, new chest pain, airway noise, or a sudden drop in BP or SpO₂ beats routine care, teaching and paperwork.

Five rights of delegation (NCSBN)

Right task · right circumstance · right person · right directions and communication · right supervision and evaluation. The RN stays accountable for the outcome.

The RN never delegates

Initial assessment, care planning, evaluation, initial teaching, care of unstable patients, nursing judgment. IV push medications, blood transfusion monitoring, and new admissions stay with the RN.

Who can do what (general guide; state rules and facility policy apply)

Role	Appropriate	Not appropriate
RN	Assessment, teaching, care plans, unstable or complex patients, IV meds and blood, admissions and discharges	–
LPN/LVN	Stable patients with predictable outcomes; oral, SC, IM meds; dressing changes; tube feedings; data collection; reinforce teaching; urinary catheters	Initial assessment, care planning, new teaching, unstable patients (IV tasks vary by state)
Assistive personnel (UAP, CNA)	ADLs, bathing, feeding (no swallowing issues), ambulation, turning, vital signs on stable patients, I&O, weights, specimen collection, bed making, point-of-care glucose (per facility)	Assessment, teaching, medications, judging what a finding means, care of unstable patients

Disaster triage (START)

Red: immediate	Life-threatening but survivable with quick care (airway problem, shock, RR >30)
Yellow: delayed	Serious but can wait (fractures without shock)
Green: minor	"Walking wounded"
Black: expectant	Dead or not expected to survive with available resources

To free beds in a disaster, discharge the most stable patients first.

Handoff: SBAR

Situation (what's happening now) · Background (history, relevant data) · Assessment (what you think the problem is) · Recommendation (what you need). Read back verbal and phone orders.

Memory hook"Stable and predictable → LPN. Routine and unchanging → UAP. Anything needing judgment → RN."

Legal and Ethical Practice

Principles, consent, privacy, documentation and reporting

Fundamentals

Ethical principles

Autonomy	Respecting the patient's right to decide (including refusal)
Beneficence	Doing good
Nonmaleficence	Doing no harm
Justice	Fair distribution of care
Fidelity	Keeping promises
Veracity	Telling the truth
Accountability	Taking responsibility for your actions

Legal terms

Negligence vs. malpractice	Failure to act as a reasonable person would; malpractice is professional negligence
Elements of malpractice	Duty, breach of duty, causation, damages (harm)
Assault / battery	Threat of touch / unwanted touch (e.g., treating without consent)
False imprisonment	Restraining or detaining without legal cause or order
Defamation	Slander (spoken) / libel (written)

Consent and advance directives

Valid consent: competent adult, informed, voluntary. Minors need a parent or guardian, except emancipated minors and situations allowed by state law (e.g., STI, contraception, pregnancy care).
In a true emergency, implied consent applies.
Advance directives: living will (wishes) and durable power of attorney for health care (decision-maker). Ask about them on admission (Patient Self-Determination Act).
DNR means no CPR, not "no care". POLST: portable medical orders for seriously ill patients.
Leaving against medical advice: explain risks, notify the provider, have them sign the AMA form if willing, document.

Privacy (HIPAA)

Share only the minimum necessary, only with people involved in care or authorized by the patient.
No details by phone unless the caller is verified (e.g., a code or password).
Never post anything about patients on social media, even without names.
Patients can see and request copies of their records.
Log off; don't look up records you don't need (including your own family's).

Documentation

Facts, objective, timely; quote the patient where useful.
Errors: follow the electronic correction process (paper: single line, "error", initials). Never delete, erase or use correction fluid.
Late entries labeled as late.
Incident reports are for quality improvement: don't mention them in the chart; document only the event and care given.

Mandatory reporting

Suspected child abuse or neglect, elder or dependent-adult abuse (proof isn't required).
Certain communicable diseases (to the health department).
Some injuries (e.g., gunshot wounds), per state law.
Impaired or unsafe practice by a colleague: report through the chain of command.

Good Samaritan laws protect emergency care given in good faith, within your training, off duty and without payment.

Priority An order you believe is unsafe: don't carry it out; clarify with the prescriber, and if still unsafe, use the chain of command. Following an unsafe order doesn't protect you.

Acute Kidney Injury and Chronic Kidney Disease

KDIGO definitions, causes and nursing care

Med-Surg · Renal

Acute kidney injury (AKI)

KDIGO: creatinine rises ≥0.3 mg/dL within 48 h, or to ≥1.5× baseline within 7 days, or urine output <0.5 mL/kg/h for 6 h.

Prerenal	↓ blood flow: dehydration, bleeding, HF, shock. BUN:creatinine often >20:1
Intrarenal	Kidney tissue damage: acute tubular necrosis (prolonged low flow, nephrotoxins: contrast, aminoglycosides, vancomycin, NSAIDs), glomerulonephritis
Postrenal	Obstruction: enlarged prostate, stones, tumors, blocked catheter

Nursing care in AKI

Strict I&O, daily weight, urine output hourly if critical.
Watch for hyperkalemia (peaked T waves), fluid overload, metabolic acidosis.
Avoid nephrotoxins; adjust drug doses to kidney function; check catheter patency first if urine stops.
Phases: oliguric → diuretic (watch for dehydration, low K⁺ and Na⁺) → recovery.

Dialysis indications: AEIOU Acidosis · Electrolytes (high K⁺) · Intoxication (dialyzable drugs) · Overload (fluid) · Uremia (confusion, pericarditis).

Chronic kidney disease (CKD): stages by GFR

Stage	eGFR (mL/min/1.73 m²)	Meaning
G1	≥90	Normal GFR with kidney damage (e.g., protein in urine)
G2	60–89	Mildly decreased
G3a / G3b	45–59 / 30–44	Moderately decreased
G4	15–29	Severely decreased: prepare for dialysis or transplant
G5	<15	Kidney failure

GFR is how much blood the glomeruli filter per minute (not total blood flow). Albuminuria is staged A1–A3 (urine albumin-to-creatinine ratio <30, 30–300, >300 mg/g). Leading causes: diabetes and hypertension.

What goes wrong in CKD

Anemia (less erythropoietin) → ESAs + iron; hold ESA if Hgb is high (~>11); raises BP and clot risk.
High phosphate, low calcium → bone disease: phosphate binders with meals, active vitamin D.
High K⁺, metabolic acidosis, fluid overload, hypertension.
Uremia: fatigue, nausea, itching, confusion.

Slowing CKD Updated

BP control; ACE inhibitor or ARB if albuminuria.
SGLT2 inhibitor (with or without diabetes) for most with eGFR ≥20.
In type 2 diabetes: finerenone; semaglutide (GLP-1 RA) also protects kidneys.
Avoid: NSAIDs, magnesium laxatives and antacids, phosphate enemas; caution with contrast and metformin.
Diet: limit sodium; K⁺ and phosphorus as labs require; protein ~0.8 g/kg before dialysis (higher once on dialysis).

Dialysis and Kidney Transplant

Hemodialysis, peritoneal dialysis and transplant nursing

Med-Surg · Renal

Hemodialysis access

AV fistula (preferred: lowest infection risk; takes weeks to months to mature), AV graft, or central catheter.
Check every shift: feel the thrill (vibration), listen for the bruit (whoosh). Absent → clot: report now.
No BP, IVs, blood draws, tight sleeves, jewelry or sleeping on the access arm.
Watch for bleeding after needle removal; signs of infection.

Around hemodialysis

Weigh before and after; vital signs; labs.
Hold antihypertensives and dialyzable drugs before dialysis as ordered; give after.
Hypotension and muscle cramps during treatment (fluid removed too quickly).
Dialysis disequilibrium syndrome (early sessions): headache, nausea, restlessness, confusion, seizures.
Bleeding risk (heparin used during dialysis).

Peritoneal dialysis (PD)

Fluid (dialysate) runs into the abdomen, dwells, then drains out: inflow → dwell → outflow.
Warm the dialysate (dry heat, never a microwave): reduces cramping.
Strict aseptic technique with exchanges and catheter care.
Outflow should be clear, pale yellow, and about equal to or more than inflow.

Cloudy outflow + abdominal pain + fever = peritonitis: report, send a sample.
Poor outflow: check for kinks, reposition the patient, check for constipation (full bowel blocks drainage).
Shortness of breath during dwell: raise the head of bed.
Dextrose in dialysate → weight gain, high glucose; protein loss → higher-protein diet.

Dialysis diet

Higher protein (lost in dialysis).
Limit sodium, potassium, phosphorus; fluid limit (often urine output + ~500–1,000 mL/day on hemodialysis).
Thirst tips: ice chips (count as fluid), sugar-free hard candy, small cups.
High-K⁺ foods: bananas, oranges, potatoes, tomatoes, avocados, dried fruit, salt substitutes.

Kidney transplant

Rejection: fever, ↓ urine output, rising creatinine, weight gain, tenderness over the graft, ↑ BP.
Lifelong immunosuppressants (tacrolimus, mycophenolate, steroids): take on schedule; drug levels; no grapefruit with tacrolimus/cyclosporine.
Infection risk: hand hygiene, avoid sick contacts, no live vaccines; skin cancer screening.
Large urine volumes early: watch fluids and electrolytes.

UTI, Kidney Stones and BPH

Common urinary problems

Med-Surg · Renal

Urinary tract infection

Cystitis: burning, frequency, urgency, suprapubic pain, cloudy or foul urine. Older adults: may show only new confusion or falls.
Pyelonephritis: fever, chills, flank pain, costovertebral angle tenderness, nausea.
Urinalysis (nitrites, leukocyte esterase) and urine culture before antibiotics.
Treat: nitrofurantoin, TMP-SMX or fosfomycin for simple cystitis; phenazopyridine for burning (orange urine, ≤2 days).
Prevent: fluids, void after intercourse, wipe front to back, don't hold urine. Don't treat bacteria in urine without symptoms (except pregnancy and before urologic procedures).

Kidney stones

Sudden, severe flank pain radiating to the groin, nausea, hematuria. Non-contrast CT.
Pain control first (NSAIDs such as ketorolac; opioids as needed); tamsulosin helps some ureteral stones pass.
Strain all urine; send the stone for analysis.
Fluids so urine output is >2–2.5 L/day.
Fever with an obstructing stone = emergency (infected, blocked kidney).
Procedures: lithotripsy (shock waves: bruising, blood in urine), ureteroscopy.

Preventing stones by type

Stone	Prevention
Calcium oxalate (most common)	Keep normal dietary calcium (1,000–1,200 mg/day: low calcium diets make stones more likely). Limit sodium, animal protein and high-oxalate foods (spinach, rhubarb, nuts, chocolate, beets, tea). Thiazides and citrate may be prescribed
Uric acid	Limit purines (organ meats, shellfish, red meat, beer); allopurinol; potassium citrate to make urine less acidic
Struvite	Linked to UTIs: treat infection

Benign prostatic hyperplasia (BPH)

Frequency, nocturia, weak stream, hesitancy, dribbling, retention.
Alpha-1 blockers (tamsulosin): dizziness, orthostatic hypotension; tell the eye surgeon before cataract surgery.
5-alpha reductase inhibitors (finasteride): take 6–12 months to work; pregnant people shouldn't handle crushed or broken tablets.
Avoid decongestants and anticholinergics (cause retention).
Prostate cancer screening (PSA) for ages 55–69 is an individual decision.

After TURP: continuous bladder irrigation

Purpose: flushes clots out of the bladder.
Titrate the irrigation to keep urine light pink to clear. Bright red with clots → increase flow and notify.
True urine output = total drainage − irrigant used.
Bladder spasms are common (antispasmodics); check for clots blocking the catheter.
Watch for hyponatremia from absorbed irrigation (confusion, nausea, slow pulse).
After discharge: avoid straining and heavy lifting; fluids; some dribbling is temporary.

Upper GI: GERD, Ulcers and GI Bleeding

Reflux, peptic ulcer disease, bleeding and dumping syndrome

Med-Surg · GI

GERD and hiatal hernia

Heartburn, regurgitation, worse after meals and lying down; chronic cough, hoarseness.
Lifestyle: raise the head of the bed 6–8 in; small meals; nothing for 2–3 h before bed; lose weight; stop smoking; limit fatty foods, chocolate, peppermint, caffeine, alcohol, spicy or acidic foods if they trigger symptoms.
PPIs or H2 blockers.
Long-term: Barrett's esophagus (cancer risk): surveillance endoscopy.

Peptic ulcer disease

Main causes: H. pylori and NSAIDs.
Gastric ulcer: pain soon after eating; weight loss. Duodenal ulcer: pain 2–3 h after meals and at night, relieved by food.
Treat H. pylori (PPI + antibiotics, retest for cure); stop NSAIDs; PPI.
Perforation: sudden severe pain, rigid board-like abdomen, rebound tenderness, shock → surgical emergency.

GI bleeding

Hematemesis	Bright red or coffee-ground vomit (upper GI)
Melena	Black, tarry stool (upper GI; iron and bismuth also darken stool)
Hematochezia	Bright red rectal blood (lower GI, or a massive upper bleed)

Two large-bore IVs, fluids, type and crossmatch; transfuse usually if Hgb <7 (higher in heart disease).
IV PPI; NPO; endoscopy (usually within 24 h).
Variceal bleeding (cirrhosis): octreotide, antibiotics, endoscopic banding.
Watch for shock: tachycardia, ↓ BP, restlessness, cool skin, ↓ urine.
BUN may rise (blood digested in the gut).

Dumping syndrome (after gastric surgery)

Early (10–30 min after eating): cramping, diarrhea, dizziness, tachycardia, sweating.
Late (1–3 h): hypoglycemia.
Prevent: small frequent meals; higher protein and fat, low simple sugars; no fluids with meals (drink 30 min before or after); lie down after eating.

NG tubes

Measure nose → earlobe → xiphoid; confirm placement by X-ray before first use for feeding or meds.
Decompression: low intermittent suction; check output color and amount; irrigate per order.
Watch for fluid and electrolyte loss (metabolic alkalosis, low K⁺).
Oral care and nares care; keep head up.

Lower GI Disorders

IBD, diverticulitis, appendicitis, bowel obstruction and colorectal screening

Med-Surg · GI

Crohn's disease vs. ulcerative colitis

	Crohn's disease	Ulcerative colitis
Where	Anywhere mouth to anus (often terminal ileum); skip lesions; full wall thickness	Colon and rectum only; continuous; inner lining
Stools	Diarrhea, often not bloody; fatty stools	Bloody diarrhea, many times a day; urgency
Complications	Fistulas, strictures, obstruction, malabsorption (B12, iron)	Toxic megacolon, perforation, hemorrhage, colon cancer
Surgery	Not curative: disease can recur elsewhere	Removing the colon and rectum is curative

Treatment: aminosalicylates (mesalamine, mainly UC), steroids for flares only, immunomodulators, biologics (infliximab, adalimumab, vedolizumab, ustekinumab, risankizumab), JAK inhibitors. Screen for TB and hepatitis B before biologics. During flares: low-residue diet, small meals, fluids, avoid trigger foods; TPN if severe.

Diverticulitis

LLQ pain, fever, change in bowel habits.
Mild, uncomplicated cases may not need antibiotics; clear liquids → advance as tolerated.
Prevention: high-fiber diet, fluids, activity. Updated No need to avoid nuts, seeds or popcorn.
Perforation, abscess → surgery; possible colostomy.

Appendicitis

Pain starts around the navel, moves to the RLQ (McBurney's point); rebound tenderness, low fever, nausea, loss of appetite.
No heat to the abdomen and no laxatives or enemas (risk of rupture).
Sudden relief of pain may mean rupture → peritonitis (rigid abdomen, fever, shock).
Appendectomy; antibiotics.

Bowel obstruction

Small bowel: early, frequent vomiting (may smell feculent), cramping, distension.
Large bowel: marked distension, constipation, late vomiting.
Bowel sounds high-pitched early, then absent.
NPO, NG tube to suction, IV fluids, electrolytes; surgery if strangulated (fever, constant pain, tachycardia).

Colorectal cancer screening (USPSTF)

Average risk: ages 45–75. Options: colonoscopy every 10 years · FIT (stool) every year · stool DNA-FIT every 1–3 years · CT colonography or flexible sigmoidoscopy every 5 years. A positive stool test needs a follow-up colonoscopy. Earlier screening for family history or IBD.

Colonoscopy prep: clear liquids the day before; bowel prep until output is clear yellow; avoid red/purple liquids.

Cirrhosis and Hepatitis

Complications of liver disease and the hepatitis viruses

Med-Surg · Liver

Cirrhosis

Causes: alcohol, MASLD (metabolic dysfunction-associated steatotic liver disease, the 2023 name for NAFLD) Updated, hepatitis B and C.

Portal hypertension → varices	Can bleed massively. Beta blocker (propranolol, carvedilol) to prevent; banding; avoid straining
Ascites	Sodium limit (~2 g/day), spironolactone + furosemide, paracentesis (void first; watch BP; albumin after large volumes); measure girth and weight
Hepatic encephalopathy	↑ ammonia: confusion, asterixis (flapping tremor), sleepiness. Lactulose (2–3 soft stools/day) + rifaximin. Don't restrict protein
Bleeding	Low clotting factors and platelets: bleeding precautions
Others	Jaundice, itching, spontaneous bacterial peritonitis, kidney failure (hepatorenal)

Cirrhosis: drugs and diet

Acetaminophen up to 2 g/day is the preferred pain reliever. Avoid NSAIDs (bleeding, kidney failure).
Avoid or minimize sedatives (benzodiazepines, opioids): they trigger encephalopathy.
No alcohol.
Adequate protein (1.2–1.5 g/kg/day), small frequent meals and a late-evening snack.
Vaccinate against hepatitis A and B if not immune.

PriorityVomiting blood in a patient with cirrhosis: variceal bleed. Airway, two large IVs, call for help, prepare for octreotide, transfusion and endoscopy.

Viral hepatitis

Virus	Spread	Key points
A	Fecal-oral (food, water)	Short illness, no chronic form. Vaccine. Hand hygiene; contact precautions if incontinent
B	Blood, sex, birth	Can become chronic (liver cancer, cirrhosis). Vaccine. Antivirals (tenofovir, entecavir) for chronic infection
C	Blood (injection drug use, past transfusions)	Often silent and chronic. No vaccine, but curable (>95%) with 8–12 weeks of direct-acting antiviral pills. Updated Screen all adults at least once
D	Blood	Only with hepatitis B
E	Fecal-oral	Dangerous in pregnancy

Signs of acute hepatitis: fatigue, nausea, RUQ discomfort, dark urine, clay-colored stools, jaundice. Rest; avoid alcohol and liver-toxic drugs.

Memory hook Hepatitis A and E come from the bowel (vowels → bowels). B, C and D come from blood and body fluids.

Pancreatitis and Gallbladder Disease

Acute and chronic pancreatitis, cholecystitis

Med-Surg · GI

Acute pancreatitis

Causes: gallstones, alcohol, very high triglycerides, after ERCP, some drugs.
Severe epigastric or LUQ pain radiating to the back, worse lying flat; better sitting up and leaning forward.
Nausea, vomiting, fever, tachycardia.
Cullen's sign (bruising around the navel), Grey Turner's sign (flank bruising): bleeding, severe disease.
Labs: lipase ≥3× upper limit; high glucose; low calcium (check Chvostek's and Trousseau's signs).

Treatment Updated

IV fluids (lactated Ringer's), moderate and goal-directed: too much fluid causes harm.
Pain control, including opioids.
Early oral feeding (within 24–72 h, low-fat) once pain and nausea allow. Prolonged NPO to "rest the pancreas" is outdated.
If unable to eat: tube feeding is preferred over TPN.
NG tube only for vomiting or ileus. No routine antibiotics.
Gallstone pancreatitis: cholecystectomy during the same admission.

Chronic pancreatitis

Ongoing pain, weight loss, fatty stools (steatorrhea), diabetes.
Pancreatic enzymes with meals and snacks; insulin; stop alcohol and smoking.
Small, low-fat meals.

Cholecystitis and gallstones

RUQ pain after fatty meals, radiating to the right shoulder or scapula; Murphy's sign; nausea, fever.
Blocked bile duct: jaundice, dark urine, clay-colored stools, itching.
Ultrasound; laparoscopic cholecystectomy; ERCP for duct stones.
After laparoscopic surgery: shoulder pain from CO₂ gas: walk, warm packs per order.
Low-fat diet if symptoms persist.

Priority Pancreatitis can cause shock, ARDS, low calcium (tetany, seizures), and high glucose. Watch breathing, BP, urine output, calcium and glucose closely in the first 48 hours.

DKA, HHS and Diabetes Care

Hyperglycemic crises (2024 ADA/EASD consensus) and long-term care

Med-Surg · Endocrine

DKA vs. HHS

	Diabetic ketoacidosis (DKA)	Hyperosmolar hyperglycemic state (HHS)
Who	Mostly type 1; any age; onset hours	Mostly type 2, older adults; onset over days
Glucose	≥200 mg/dL (or known diabetes; can be near-normal with SGLT2 inhibitors)	≥600 mg/dL
Acid–base	pH <7.3 and/or HCO₃⁻ <18	pH ≥7.3, HCO₃⁻ ≥15
Ketones	High (β-hydroxybutyrate ≥3.0 mmol/L)	Minimal
Signs	Kussmaul breathing, fruity breath, abdominal pain, vomiting, dehydration	Severe dehydration, osmolality >300, confusion, seizures, coma

In DKA, glucose is stuck in the blood: cells can't use it without insulin, so the body burns fat and makes ketones. Common triggers: infection, missed insulin, new diagnosis.

Treatment order

Fluids first: isotonic (0.9% saline or balanced crystalloid), about 500–1,000 mL/h for the first 2–4 h (smaller boluses in older adults or heart or kidney failure), then adjust.
Check potassium before insulin. K⁺ <3.5 → replace K⁺ before starting insulin. 3.5–5.0 → add K⁺ to fluids. >5.0 → no K⁺, recheck often.
Insulin: IV regular insulin infusion (or SC rapid-acting in mild–moderate DKA).
Add dextrose (5–10%) when glucose falls below ~250 mg/dL, and keep insulin running until the crisis resolves.
Bicarbonate only if pH <7.0.
Resolved (DKA): pH ≥7.3, HCO₃⁻ ≥18, ketones low. Give SC basal insulin 1–2 h before stopping the drip.

Monitor

Glucose every hour; K⁺, Na⁺, phosphate every 2–4 h.
Cardiac monitor (K⁺ shifts into cells with insulin → hypokalemia).
Urine output, mental status. Children: cerebral edema (headache, falling LOC): correct slowly.

Long-term diabetes care

A1C every 3–6 months; dilated eye exam yearly; urine albumin and eGFR yearly; BP and lipids.
Foot care: inspect daily (mirror), wash and dry well (especially between the toes), moisturize but not between the toes, well-fitting shoes, never barefoot, no heating pads or hot soaks, podiatry for nails if neuropathy.
Exercise: check glucose first; carry fast carbs; delay exercise if glucose >250 with ketones.
Continuous glucose monitors are widely used: know how to read trend arrows.

Priority A diabetic patient who is confused, sweaty and shaky: check glucose. If you can't check quickly and the patient is symptomatic, treat as hypoglycemia: low glucose kills faster than high glucose.

Thyroid and Parathyroid Disorders

Hypo- and hyperthyroidism, crises, and thyroid surgery

Med-Surg · Endocrine

	Hypothyroidism (e.g., Hashimoto's)	Hyperthyroidism (e.g., Graves')
Signs	Fatigue, cold intolerance, weight gain, constipation, dry skin, hair loss, bradycardia, slow thinking, depression, heavy periods	Anxiety, heat intolerance, weight loss, diarrhea, tachycardia/A-fib, tremor, insomnia, goiter; Graves': bulging eyes (exophthalmos)
Labs (primary disease)	TSH high, free T4 low	TSH low, free T4/T3 high
Treatment	Levothyroxine (empty stomach, lifelong; start low in older and cardiac patients)	Methimazole (PTU in 1st trimester), beta blockers, radioactive iodine, surgery
Crisis	Myxedema coma: hypothermia, bradycardia, hypotension, hypoventilation, low Na⁺ and glucose, coma → IV levothyroxine, steroids, ventilation, passive warming; avoid sedatives	Thyroid storm: high fever, severe tachycardia, delirium, vomiting → beta blocker, PTU or methimazole, then iodine, steroids, cooling with acetaminophen (not aspirin)

After thyroidectomy

Airway: semi-Fowler's, support the neck; tracheostomy kit, suction and oxygen at the bedside.
Bleeding: check the dressing and the back of the neck; a tight feeling or swelling = hematoma (airway risk).
Hypocalcemia (parathyroid injury): tingling around the mouth and fingers, Chvostek's and Trousseau's signs, laryngospasm → IV calcium gluconate at the bedside.
Voice: ask the patient to speak every few hours. Hoarseness = laryngeal nerve injury.
Lifelong levothyroxine after total thyroidectomy.

Parathyroid

Hyperparathyroidism → high calcium: "stones, bones, groans, moans": kidney stones, bone pain and fractures, abdominal pain and constipation, fatigue, depression, confusion. Fluids, avoid thiazides, cinacalcet, surgery.
Hypoparathyroidism → low calcium: tingling, muscle cramps, tetany, seizures, long QT. Calcium and active vitamin D; IV calcium gluconate for severe symptoms.

Memory hook Chvostek = cheek (tap the facial nerve → twitch). Trousseau = BP cuff on the arm → hand spasm. Both = low calcium.

Radioactive iodine (for hyperthyroidism)

Not in pregnancy or breastfeeding. For several days: distance from others (especially children and pregnant people), sleep alone, flush twice, separate laundry and utensils, as instructed. Hypothyroidism often follows: lifelong levothyroxine.

Eye care in Graves'

Raise the head of the bed, artificial tears, sunglasses, tape lids if they don't close at night, stop smoking (worsens eye disease).

Adrenal and Pituitary Disorders

Addison's, Cushing's, pheochromocytoma, SIADH and diabetes insipidus

Med-Surg · Endocrine

	Addison's disease (too little cortisol and aldosterone)	Cushing's syndrome (too much cortisol)
Signs	Fatigue, weight loss, hypotension, bronze hyperpigmentation, salt craving, nausea	Moon face, buffalo hump, central obesity, thin arms and legs, purple striae, bruising, weakness, mood changes, poor wound healing
Labs	↓ Na⁺, ↑ K⁺, ↓ glucose	↑ glucose, ↓ K⁺, ↑ Na⁺; hypertension
Treatment	Hydrocortisone (larger morning dose) + fludrocortisone; stress dosing during illness; emergency injection kit; medical ID	Most often from steroid medication: taper if possible; otherwise surgery (pituitary or adrenal) or medication
Nursing	Fluids, salt intake; never miss doses	Infection prevention, glucose checks, fall and fracture prevention, skin care

Adrenal (Addisonian) crisis Severe hypotension or shock, vomiting, abdominal pain, confusion, fever. Triggered by stress, infection, surgery, or stopping steroids suddenly.
→ IV hydrocortisone (e.g., 100 mg) immediately + IV fluids (saline with dextrose); treat the cause.

Pheochromocytoma

Adrenal tumor releasing adrenaline: episodes of severe hypertension, headache, sweating, palpitations. Don't palpate the abdomen (can trigger a surge). Before surgery: alpha blocker first, then beta blocker. Primary aldosteronism: hypertension + low K⁺; spironolactone or surgery.

SIADH vs. diabetes insipidus

	SIADH (too much ADH)	Diabetes insipidus (too little ADH effect)
Water	Retained: weight gain without edema	Lost: huge volumes of urine (3–20 L/day), extreme thirst
Serum sodium	Low (dilutional)	High
Urine	Concentrated: high specific gravity	Dilute: specific gravity <1.005
Causes	Small cell lung cancer, brain injury, pneumonia, drugs (SSRIs, carbamazepine)	Head injury, pituitary surgery (central); lithium (kidney type)
Treatment	Fluid restriction; hypertonic saline (slowly) if severe symptoms; vaptans; seizure precautions; daily weight	Central: desmopressin (watch for low Na⁺, weight gain). Kidney type: thiazide, stop lithium. Replace fluids

New names (2022): central DI = arginine vasopressin deficiency (AVP-D); nephrogenic DI = AVP resistance (AVP-R). Updated

Memory hook SIADH: "Soaked": holding water, sodium diluted. DI: "Dry": peeing it all out, sodium concentrated.
Addison's: add the hormones back. Cushing's: cushion of fat from too much cortisol.

Neuro Assessment and Increased ICP

Glasgow Coma Scale, pupils, and protecting the brain

Med-Surg · Neuro

Glasgow Coma Scale

Eye opening	Verbal	Motor
4 Spontaneous	5 Oriented	6 Obeys commands
3 To voice	4 Confused	5 Localizes pain
2 To pain	3 Inappropriate words	4 Withdraws from pain
1 None	2 Sounds only	3 Abnormal flexion (decorticate)
	1 None	2 Extension (decerebrate)
		1 None

Total 3–15. ≤8 = severe: protect the airway ("less than 8, intubate"). A drop of 2 or more points is significant.

Signs of increased ICP

Earliest: change in level of consciousness (restless, confused, sleepy).
Headache, vomiting (often without nausea), vision changes.
Pupil changes: one pupil dilating and sluggish = pressure on cranial nerve III: emergency.
Posturing: decorticate (arms flexed "to the core") → decerebrate (arms extended: worse).
Late: Cushing's triad: rising systolic BP (wide pulse pressure), bradycardia, irregular breathing.

Normal ICP 5–15 mmHg. CPP = MAP − ICP (target ~60–70).

Lowering ICP: nursing care

HOB 30°, head and neck midline; avoid neck and extreme hip flexion.
Avoid Valsalva: stool softeners; no straining, coughing or isometric exercise.
Cluster care with rest periods; quiet, dim room; limit visitors if stimulation raises ICP.
Suction only when needed, ≤10 sec, pre-oxygenate.

Normal temperature (treat fever), normal CO₂ (PaCO₂ 35–45; brief hyperventilation only for impending herniation), oxygenation, glucose control.
Mannitol or hypertonic saline; sedation; seizure prevention; drain CSF if a ventricular drain is in place.
Corticosteroids are not used for traumatic brain injury (they raise mortality). Updated Dexamethasone is used for swelling around brain tumors.

Head injury clues

Epidural hematoma (artery): brief loss of consciousness, a lucid interval, then rapid decline: emergency surgery.
Subdural hematoma (veins): slower; older adults and people on anticoagulants; can be chronic (weeks).
Basilar skull fracture: raccoon eyes, Battle's sign (bruising behind the ear), clear fluid from nose or ear (CSF: "halo" on gauze, positive for glucose). No nasal suctioning or NG tube; don't blow the nose.

Pupils and cranial nerves

PERRLA: pupils equal, round, reactive to light and accommodation.
Pinpoint pupils: opioids, pontine lesion. Fixed dilated: herniation, anoxia, atropine.
CN quick checks: gag and swallow (IX, X), facial symmetry (VII), tongue midline (XII), eye movements (III, IV, VI).

Seizures and Meningitis

Seizure types, status epilepticus, and CNS infection

Med-Surg · Neuro

Seizure types

Focal aware	Patient stays conscious; twitching, odd sensations
Focal impaired awareness	Staring, lip smacking, picking at clothes; confused afterwards
Generalized tonic-clonic	Stiffening (tonic) then jerking (clonic); possible incontinence, tongue biting; postictal confusion and sleepiness
Absence	Brief staring spells (seconds), mostly children
Myoclonic / atonic	Sudden jerks / sudden loss of tone ("drop attacks": helmet)

Triggers: missed medications, sleep loss, alcohol or withdrawal, fever, low glucose or sodium, flashing lights.

Status epilepticus (seizure ≥5 min, or repeated without recovery)

Airway, oxygen, side-lying, suction; check glucose.
Benzodiazepine first: IV lorazepam, or IM midazolam (or intranasal/rectal options) if no IV.
Then a second-line IV drug: levetiracetam, fosphenytoin, or valproate.
Still seizing: anesthesia and intubation.

Teaching

Take medications on time, never stop suddenly; medical ID; no driving until cleared under state law; don't swim or bathe alone; folic acid if planning pregnancy; seizure diary.

Bacterial meningitis

Fever, severe headache, stiff neck, light sensitivity, confusion, vomiting.
Kernig's sign: pain when straightening the knee with the hip flexed. Brudzinski's sign: bending the neck makes hips and knees flex.
Petechial or purple rash → meningococcal: emergency.
Lumbar puncture: bacterial = cloudy CSF, high protein, low glucose, high WBCs. Viral = clear, normal glucose.

Antibiotics immediately after blood cultures: don't delay for imaging or LP. Dexamethasone with or just before the first dose (pneumococcal).
Droplet precautions until 24 h of effective antibiotics (meningococcal).
Close contacts get preventive antibiotics.
Quiet, dark room; HOB 30°; seizure precautions; watch for ↑ICP, SIADH, septic shock, hearing loss.
Prevention: MenACWY, MenB, pneumococcal and Hib vaccines.

After lumbar puncture

Position side-lying, knees to chest (or sitting leaning forward) during the procedure. Afterwards: encourage fluids; report a headache that's worse when upright (CSF leak). Bed rest afterward is a facility preference, not proven to prevent headache.

Memory hook Kernig = Knee. Brudzinski = Bend the neck.

Spinal Cord Injury

Level of injury, shock, and autonomic dysreflexia

Med-Surg · Neuro

What the level means

C1–C4	Tetraplegia; often ventilator-dependent ("C3, 4, 5 keeps the diaphragm alive")
C5–C8	Tetraplegia with some arm and hand function; weak cough
T1–L1	Paraplegia; arms normal
Below L1	Mixed leg weakness; bowel and bladder problems

Complete injury = no function below the level. Incomplete = some preserved.

Acute care

Spinal motion restriction; jaw thrust to open the airway; log-roll.
Breathing first: watch vital capacity, cough, SpO₂ (especially cervical injuries).
Spinal shock: temporary loss of all reflexes below the injury (flaccid).
Neurogenic shock (injury at T6 or above): hypotension + bradycardia, warm dry skin → fluids, vasopressors, atropine.
High-dose steroids are no longer routine. Updated
DVT prevention, skin care, bowel and bladder programs, early rehab, emotional support.

Autonomic dysreflexia: emergency (injury at T6 or above)

Signs: sudden severe hypertension, pounding headache, bradycardia, flushing and sweating above the injury, pale cool skin below, nasal stuffiness, blurred vision.

Triggers: full bladder (most common: kinked catheter, retention), constipation or impaction, tight clothing, pressure injury, ingrown toenail, sexual activity.

Actions:

Sit the patient upright, legs down.
Loosen tight clothing.
Check the bladder: unkink or catheterize.
Check bowel (use anesthetic gel).
Check BP every 2–5 min; give antihypertensive as ordered if it stays high.
Notify the provider; teach the patient and family.

Long-term issues

Pressure injuries: turn often; teach weight shifts in the wheelchair.
Bladder: intermittent catheterization; UTI risk.
Bowel program at the same time each day.
Spasticity (baclofen), orthostatic hypotension, depression, sexuality counseling.

Memory hook Neurogenic shock = low and slow (low BP, slow HR, warm skin).
Autonomic dysreflexia = high BP from a hidden trigger below the injury: find and fix it.

Degenerative Neurologic Disorders

MS, myasthenia gravis, Guillain-Barré, Parkinson's and ALS

Med-Surg · Neuro

Disorder	What happens	Key signs	Treatment and nursing
Multiple sclerosis	Autoimmune loss of myelin in the brain and spinal cord; relapses and remissions	Vision problems (optic neuritis, double vision), numbness, weakness, spasticity, fatigue, bladder problems; worse with heat	Disease-modifying therapies (e.g., ocrelizumab); steroids for relapses; avoid overheating; energy conservation; fall prevention
Myasthenia gravis	Antibodies block acetylcholine receptors at the muscle	Weakness that worsens with activity and later in the day; drooping eyelids, double vision, trouble chewing and swallowing	Pyridostigmine (before meals), immunotherapy, thymectomy. Crisis → respiratory failure: airway first. Avoid aminoglycosides, fluoroquinolones, magnesium
Guillain-Barré syndrome	Autoimmune attack on peripheral nerves, often after an infection	Ascending weakness (legs → up), lost reflexes, autonomic instability (BP and HR swings)	IVIG or plasma exchange; monitor breathing (vital capacity, ability to cough); most recover over months
Parkinson's disease	Loss of dopamine-producing neurons	Resting "pill-rolling" tremor, rigidity, slow movement, shuffling gait, masked face, soft voice, postural instability	Carbidopa-levodopa; fall prevention; swallowing safety; time meds precisely; exercise and PT
ALS	Loss of upper and lower motor neurons	Progressive weakness, cramps, twitching, trouble speaking and swallowing; thinking usually intact	Riluzole, edaravone, tofersen (SOD1 type); breathing support; nutrition (feeding tube); advance care planning

Myasthenic vs. cholinergic crisis

Myasthenic	Not enough medication or illness/stress: weakness, respiratory failure; HR and BP may rise
Cholinergic	Too much pyridostigmine: weakness plus SLUDGE (salivation, tearing, urination, diarrhea, GI cramps, vomiting), bradycardia, small pupils → atropine

Both can stop breathing: support ventilation first. (The old edrophonium test is no longer used.)

Parkinson's nursing

Give doses on time (late doses → freezing, falls).
High-protein meals reduce levodopa absorption: spread protein through the day.
Upright for meals; thickened liquids if needed; small bites.
Avoid haloperidol and metoclopramide (worsen symptoms).
Watch for orthostatic hypotension, constipation, depression, hallucinations.

Memory hooks Parkinson's "TRAP": Tremor, Rigidity, Akinesia (slow movement), Postural instability.
Guillain-Barré goes up like a "GB ladder" from the feet; watch the breathing as it climbs.

Fractures, Casts and Traction

Neurovascular checks and preventing complications

Med-Surg · Musculoskeletal

Fracture basics

Types: open (skin broken: infection risk), closed, comminuted (fragments), greenstick (children), compression (spine), spiral (twisting: in a non-walking child, consider abuse).
Signs: pain, deformity, swelling, shortening, crepitus, loss of function.
First aid: immobilize (splint the joints above and below), don't straighten, cover an open wound with a sterile dressing, elevate if possible, ice.
Hip fracture: leg shortened and externally rotated; surgery usually within 24–48 h.

Neurovascular checks

Compare with the other side: pain, pallor, pulses, paresthesia (numbness, tingling), paralysis (movement), poikilothermia (temperature), plus capillary refill and swelling. Check often in the first 24–48 h.

Compartment syndrome: emergency Swelling inside a closed muscle compartment cuts off blood flow (fractures, casts, crush injuries, burns).
Earliest sign: pain out of proportion to the injury, worse with passive stretching, not relieved by opioids; then numbness and tingling, tense swelling. Pallor and pulselessness are late.
Act: notify immediately; loosen dressings or have the cast split; keep the limb at heart level (not elevated, which reduces blood flow); no ice. Treatment: fasciotomy within hours.

Cast care

Plaster takes 24–72 h to dry: handle with palms, not fingertips; leave uncovered while drying. Fiberglass sets in minutes.
Elevate above heart level for the first 24–48 h and apply ice (unless compartment syndrome is suspected).
Keep dry; never push objects inside to scratch (use cool air from a hair dryer).
Report: increasing pain, numbness, cold or blue fingers or toes, hot spots, drainage, foul smell (infection or pressure injury).

Traction

Skin traction (e.g., Buck's): short-term; check skin.
Skeletal traction: pins in bone; pin care per policy (often chlorhexidine); watch for infection.
Weights hang freely: off the floor and bed; never remove or lift them without an order.
Keep body alignment; ropes on pulleys; knots away from pulleys.

Fat embolism syndrome

After long-bone or pelvic fractures, usually 24–72 h: sudden shortness of breath and hypoxemia, confusion, and a petechial rash on the chest, armpits, or conjunctiva. Oxygen, supportive care; early fracture fixation helps prevent it.

Other complications

DVT/PE (prophylaxis, early mobility) · osteomyelitis (bone infection: long antibiotic course) · infection of pins and open fractures · delayed healing (smoking, diabetes, poor nutrition).

Arthritis, Joint Replacement and Mobility Aids

OA vs. RA, hip and knee replacement, canes, crutches and walkers

Med-Surg · Musculoskeletal

	Osteoarthritis (OA)	Rheumatoid arthritis (RA)
Cause	Cartilage wear	Autoimmune inflammation of the joint lining
Joints	Weight-bearing joints (hips, knees, spine), often one side	Small joints, symmetric (hands, wrists, feet)
Stiffness	Morning stiffness <30 min; pain worse with use	Morning stiffness >1 hour; better with movement
Other signs	Bony nodes: Heberden's (end finger joints), Bouchard's (middle joints)	Fatigue, fever, nodules, swan-neck and ulnar deviation deformities; RF and anti-CCP positive
Treatment	Exercise, weight loss, acetaminophen, topical or oral NSAIDs, injections, joint replacement	DMARDs early: methotrexate (folic acid, no alcohol, liver and blood tests, birth defects), biologics (TNF inhibitors: TB screening, no live vaccines), JAK inhibitors; short-term steroids

Total hip replacement

Follow the surgeon's precautions: they depend on the approach.
Posterior approach (classic): no hip flexion >90°, no crossing legs (adduction), no turning the leg inward; abduction pillow; raised toilet seat; chair with arms.
Anterior approach: fewer restrictions (avoid extending and turning the leg out).
Dislocation: sudden severe pain, shortened or rotated leg, can't move it → notify.
DVT prophylaxis, early walking, infection signs.

Total knee replacement

Early physical therapy and walking; work toward full extension and flexion.
Pain control before PT sessions; ice.
Don't put a pillow under the knee (causes contracture).
DVT prophylaxis; watch the incision; neurovascular checks.

Mobility aids

Cane

Held on the strong side (opposite the weak leg). Move the cane and weak leg together. Top at hip level; elbow bent ~15–30°.

Crutches

Top 2–3 finger widths (1–2 in) below the armpit; weight on the hands, not the armpits; elbows bent 20–30°. Gaits: 3-point (non-weight-bearing), 2-point, 4-point, swing-through.

Walker

Lift (or roll) it forward ~6–10 in, step into it with the weak leg first, then the strong leg. Don't use it on stairs.

Memory hook: stairs"Up with the good, down with the bad." Going up: strong leg first, then crutches/cane and weak leg. Going down: crutches/cane and weak leg first.

Osteoporosis

DEXA scan: T-score ≤ −2.5 = osteoporosis (−1 to −2.5 = low bone mass). Calcium and vitamin D, weight-bearing and resistance exercise, fall prevention, no smoking, limit alcohol; medications (see Part 1, Pharmacology).

Anemia and Sickle Cell Disease

Types of anemia, and managing sickle cell crises

Med-Surg · Hematology

Anemia	Clues	Treatment and teaching
Iron deficiency	Small, pale cells (microcytic); fatigue, pallor, spoon-shaped nails, pica (craving ice or dirt); often from blood loss or pregnancy	Oral iron on an empty stomach if tolerated, with vitamin C; not with milk, antacids or tea; every-other-day dosing may absorb better. Dark stools and constipation are expected. Liquid iron through a straw (stains teeth). IV iron for intolerance
Vitamin B12 (including pernicious anemia)	Large cells (macrocytic); numbness, tingling, poor balance, memory problems, smooth red tongue	B12 injections or high-dose oral B12; lifelong in pernicious anemia (missing intrinsic factor)
Folate deficiency	Large cells without nerve symptoms; alcohol use, pregnancy, poor diet	Folic acid; leafy greens, legumes, fortified grains
Anemia of CKD	Low erythropoietin	Iron + erythropoiesis-stimulating agents; don't push Hgb too high (stroke, clots)
Aplastic anemia	Bone marrow failure: low red cells, white cells and platelets	Infection and bleeding precautions; transfusions; stem cell transplant

Most stable patients are transfused when Hgb <7 g/dL (often <8 with heart disease or surgery).

Sickle cell disease

Inherited (autosomal recessive). Red cells sickle when stressed → block small vessels and break down early.

Crisis triggers

Dehydration, infection, cold, low oxygen (high altitude), stress, overexertion.

Vaso-occlusive pain crisis

Treat pain fast (aim within 1 hour of arrival): IV opioids, often by PCA; scheduled, not just "as needed".
Hydration (oral and IV).
Oxygen only if SpO₂ is low.
Warmth: no cold packs (cold causes vessel narrowing).
Incentive spirometry to prevent acute chest syndrome.

Emergencies

Acute chest syndrome: chest pain, fever, cough, low SpO₂, new lung infiltrate: leading cause of death.
Stroke (children: yearly transcranial Doppler screening).
Splenic sequestration (young children): sudden big spleen, pallor, shock.
Fever ≥101.3°F (38.5°C), or per protocol: urgent evaluation (no working spleen → sepsis risk).

Long-term Updated

Hydroxyurea (raises fetal hemoglobin; check blood counts; avoid in pregnancy), L-glutamine, crizanlizumab.
Voxelotor was withdrawn from the market in 2024.
Gene therapies (exa-cel, lovo-cel) approved in 2023 for ages ≥12.
Children: daily penicillin until age 5; pneumococcal and meningococcal vaccines.

Blood Cancers and Bleeding Disorders

Leukemia, lymphoma, myeloma, hemophilia and platelet disorders

Med-Surg · Hematology

Leukemia

Bone marrow fills with abnormal white cells → infection (few working WBCs), bleeding (low platelets), anemia (fatigue).
ALL is the most common childhood cancer; AML, CLL and CML mostly in adults.
Diagnosis: blood counts and bone marrow biopsy (posterior iliac crest; pressure afterward).
Chemotherapy, targeted drugs, stem cell transplant (watch for graft-vs-host disease: rash, diarrhea, liver changes), CAR-T cell therapy (watch for cytokine release syndrome: fever, low BP; and neurotoxicity).

Lymphoma and myeloma

Hodgkin lymphoma: painless enlarged lymph node (often neck), Reed-Sternberg cells; good cure rates.
Non-Hodgkin lymphoma: more common, many types.
"B symptoms": fever, drenching night sweats, weight loss.
Multiple myeloma (plasma cells): "CRAB": high Calcium, Renal failure, Anemia, Bone pain and fractures. Fluids, fall precautions, careful moving.

Bleeding disorders

Condition	Key points
Hemophilia A / B	Missing factor VIII (A) or IX (B); X-linked, mostly males. Bleeding into joints (hemarthrosis): factor replacement first, then rest, ice, elevation. Emicizumab prevents bleeds in hemophilia A. No IM injections, aspirin or NSAIDs; soft toothbrush; medical ID
Von Willebrand disease	Most common inherited bleeding disorder: nosebleeds, heavy periods. Desmopressin or factor concentrates
Immune thrombocytopenia (ITP)	Antibodies destroy platelets: petechiae, bruising. Steroids, IVIG, other drugs
Heparin-induced thrombocytopenia (HIT)	Platelets drop >50% 5–10 days after heparin; clots, not bleeding, are the danger. Stop all heparin (including flushes); use argatroban or bivalirudin
DIC	Widespread clotting uses up clotting factors → bleeding: ↓ platelets and fibrinogen, ↑ PT/aPTT and D-dimer. Treat the cause; blood products

Bleeding precautions (low platelets)

Soft toothbrush; electric razor; no IM injections, rectal temperatures or enemas; gentle nose blowing; avoid aspirin and NSAIDs; apply pressure longer after needle sticks; fall prevention; watch urine, stool, gums, skin, and neuro status. Spontaneous bleeding risk rises sharply below ~20,000/mm³.

Priority A neutropenic patient with a fever, or a patient with low platelets and a new headache or confusion (possible brain bleed), needs immediate attention.

Oncology Nursing

Chemotherapy and radiation safety, side effects, emergencies and screening

Med-Surg · Oncology

Handling chemotherapy safely

Two pairs of chemo-tested gloves, impermeable gown, eye and face protection if splashing is possible.
Closed-system transfer devices; spill kit available; dispose in hazardous waste.
Body fluids may contain drug for ~48 h: gloves for handling them.
Extravasation of a vesicant: stop the infusion, leave the catheter in, aspirate, follow the antidote protocol (e.g., dexrazoxane for anthracyclines; warm vs. cold packs depend on the drug), notify.

Side effects and care

Neutropenia: blood counts lowest (nadir) ~7–14 days after chemo. Fever ≥100.4°F (38°C) = emergency: cultures and antibiotics within 1 hour.
Low platelets: bleeding precautions.
Nausea: give antiemetics before chemo (ondansetron, NK1 blockers, dexamethasone, olanzapine).
Mouth sores: soft brush, saline or baking soda rinses, no alcohol mouthwash, soft bland foods.
Fatigue (gentle exercise helps), hair loss, taste changes, neuropathy.
Immunotherapy (checkpoint inhibitors): immune side effects (colitis, pneumonitis, hepatitis, thyroid problems): report diarrhea or cough early.

Radiation therapy

External beam

Patient is not radioactive. Skin: mild soap, lukewarm water, pat dry; don't wash off markings; no lotions, powders or deodorant on the area before treatment unless approved; avoid sun and heat.

Sealed implant (brachytherapy)

Patient emits radiation while it's in place: private room; limit time, keep distance (≥6 ft when possible), use shielding; no pregnant visitors or children. A dislodged implant: long-handled forceps into a lead container: never by hand.

Unsealed (e.g., radioactive iodine)

Body fluids are radioactive for days: flush twice, separate utensils and laundry, distance from others, as instructed.

Oncologic emergencies

Tumor lysis syndrome	↑ K⁺, ↑ uric acid, ↑ phosphate, ↓ calcium after treatment starts → hydration, allopurinol or rasburicase, cardiac monitoring
Hypercalcemia	Confusion, constipation, thirst → IV fluids, zoledronic acid or denosumab, calcitonin
Spinal cord compression	New back pain → weakness, bowel or bladder changes → steroids, imaging, radiation: emergency
Superior vena cava syndrome	Swelling of face, neck and arms, distended neck veins, dyspnea → raise HOB
Cardiac tamponade, SIADH, sepsis	See relevant pages

Screening (USPSTF)

Breast	Mammogram every 2 years, ages 40–74 (2024)
Cervical	21–29: Pap every 3 yr. 30–65: HPV test every 5 yr, co-test every 5 yr, or Pap every 3 yr
Colorectal	Ages 45–75
Lung	Yearly low-dose CT, ages 50–80, ≥20 pack-years, smoking now or quit within 15 years
Prostate	PSA: individual decision, ages 55–69

Immune Disorders

HIV, lupus, anaphylaxis and transplant rejection

Med-Surg · Immune

HIV

Spread by blood, sex, and from parent to baby (pregnancy, birth, breastfeeding). Standard precautions are enough in care.
Testing: 4th-generation antigen/antibody test; viral load; CD4 count.
AIDS (stage 3): CD4 <200 cells/mm³ or an AIDS-defining infection or cancer.
Antiretroviral therapy for everyone with HIV, started as soon as possible; daily adherence prevents resistance.
Undetectable = untransmittable (U=U) by sex.

PrEP (prevention before exposure): daily pills, or long-acting injections (cabotegravir every 2 months; lenacapavir twice a year, approved 2025). New
PEP after exposure: start within 72 hours (sooner is better), take for 28 days.
Needlestick: wash with soap and water, report immediately, get evaluated for PEP.
Opportunistic infection prevention (e.g., TMP-SMX when CD4 <200); vaccines (no live vaccines if CD4 is low).
Pregnancy: ART throughout + infant prophylaxis prevents most transmission.

Systemic lupus erythematosus (SLE)

Autoimmune disease of many organs; mostly women of childbearing age.
Butterfly rash, sun sensitivity, joint pain, fatigue, fever, mouth sores, kidney disease (lupus nephritis), pleurisy or pericarditis.
Positive ANA (and more specific antibodies).
Hydroxychloroquine for nearly everyone (yearly eye exams), steroids for flares, immunosuppressants, belimumab, anifrolumab.
Sun protection; infection prevention; plan pregnancy when disease is quiet.

Anaphylaxis

Hives, swelling, wheeze, stridor, low BP, vomiting, sense of doom, within minutes of exposure.
Epinephrine IM first: 0.3–0.5 mg (1 mg/mL) in adults into the outer thigh; repeat every 5–15 min as needed.
Lay flat with legs up (sit up if struggling to breathe); oxygen; IV fluids; call for help.
Antihistamines and steroids are add-ons, not first-line.
Observe for a second (biphasic) reaction. Teach auto-injector use; nasal epinephrine spray is also available.
Latex allergy: cross-reacts with banana, avocado, kiwi, chestnut.

Transplant rejection

Hyperacute	Minutes to hours; graft removed
Acute	Days to months: fever, tenderness, falling organ function; treat with more immunosuppression
Chronic	Months to years: gradual loss of function

Lifelong immunosuppression (tacrolimus: drug levels, kidney toxicity, tremor; mycophenolate: birth defects, GI upset; steroids). Infection precautions, no live vaccines, sun protection and skin checks, no grapefruit with tacrolimus or cyclosporine.

Burns

Depth, size, fluid resuscitation and the phases of burn care

Med-Surg · Integumentary

Burn depth

Superficial	Epidermis only; red, painful, no blisters (sunburn); heals in ~1 week
Superficial partial-thickness	Into the upper dermis; blisters, moist, pink, very painful; heals in 2–3 weeks
Deep partial-thickness	Deeper dermis; mottled red and white, less pain, may need grafting
Full-thickness	Whole dermis; white, brown or leathery, painless (nerves destroyed); needs grafting

Burn size: rule of nines (adult)

Head and neck	9%	Each arm	9%
Front of trunk	18%	Back of trunk	18%
Each leg	18%	Perineum	1%

Children have bigger heads and smaller legs: use the Lund-Browder chart. The patient's own palm (with fingers) ≈ 1% of body surface. Don't count superficial burns in the total.

Emergent phase (first ~24–48 h)

Airway first: inhalation injury signs: burns to face or neck, singed nasal hair, soot in mouth or sputum, hoarseness, stridor → early intubation.
Carbon monoxide: pulse oximetry reads falsely normal: check carboxyhemoglobin; give 100% oxygen.
Capillary leak → fluid shifts out of vessels → hypovolemia, high K⁺ (cell damage), high hematocrit.
IV opioids for pain (not IM); tetanus; stress-ulcer prophylaxis; NG tube for large burns (ileus).

Fluid resuscitation Parkland formula: 4 mL × kg × %TBSA (partial + full thickness) of lactated Ringer's over 24 h. Half in the first 8 h from the time of the burn, half over the next 16 h.

Adjust to urine output 0.5 mL/kg/h in adults (~30–50 mL/h), 1 mL/kg/h in children <30 kg.

Burn centers now often start lower (2 mL × kg × %TBSA in adults) to avoid over-resuscitation. Know Parkland for exams.

Example: 80 kg, 40% TBSA → 4 × 80 × 40 = 12,800 mL. First 8 h: 6,400 mL (800 mL/h).

Acute and rehab phases

Fluid moves back (~48–72 h): diuresis, low K⁺.
Infection is the main threat: strict asepsis; no plants or flowers.
Wound care, debridement, grafts (keep graft immobile).
High-calorie, high-protein diet; premedicate before dressing changes.
Prevent contractures: positioning, splints, range of motion; pressure garments (~23 h/day) for scars; psychosocial support.

Special burns

Electrical: damage is deeper than it looks: cardiac monitoring (dysrhythmias), muscle breakdown (dark urine: keep urine output higher), compartment syndrome.
Chemical: brush off dry chemicals, then flush with large amounts of water.
Circumferential burns: watch circulation and breathing (escharotomy).
First aid: cool running water (not ice) ~20 min; remove jewelry and clothing; cover with clean dry cloth.

Common Skin Conditions

Infections, infestations, chronic skin disease and skin cancer

Med-Surg · Integumentary

Condition	Key signs	Care
Cellulitis	Spreading red, warm, tender skin; fever	Mark the border with a pen to track spread; elevate; antibiotics
Herpes zoster (shingles)	Painful blisters in a band on one side of the body (one dermatome)	Antivirals within 72 h; pain control. Contagious to people without chickenpox immunity until crusted. Localized, normal immune system, fully covered: standard precautions. Disseminated, or any shingles in an immunocompromised patient: airborne + contact. Shingrix: 2 doses for adults ≥50 (≥19 if immunocompromised)
Impetigo	Honey-colored crusts (children)	Topical or oral antibiotics; contact precautions; keep nails short
Scabies	Intense itching, worse at night; burrows between fingers and wrists	Permethrin neck down, left on 8–14 h, repeat in 1 week; treat all close contacts at once; wash linens hot or bag for 3+ days. Itching can last weeks
Head lice	Itching; nits on hair shafts near the scalp	Pediculicide; nit comb; wash bedding hot; bag items 2 weeks
Psoriasis	Thick red plaques with silvery scale (elbows, knees, scalp)	Topical steroids, vitamin D creams, phototherapy, biologics; not contagious
Atopic dermatitis (eczema)	Dry, itchy patches; flexures in older children	Moisturize right after bathing; avoid triggers; topical steroids

Skin cancer

Basal cell: most common; pearly bump; rarely spreads.
Squamous cell: scaly, crusted lesion; can spread.
Melanoma: most deadly. Check moles with ABCDE: Asymmetry, Border irregular, Color varied, Diameter >6 mm, Evolving.

Sun safety

Broad-spectrum sunscreen SPF 30+; reapply every 2 h and after swimming.
Shade, hats, sunglasses; avoid midday sun.
No tanning beds.
Monthly skin self-checks; extra care with photosensitizing drugs.

Memory hook Shingles stays on one side because it follows one nerve. Scabies itch is worst at night, and the whole household gets treated at the same time.

Eye and Ear Disorders

Cataracts, glaucoma, retinal problems, hearing and balance

Med-Surg · Sensory

Condition	Signs	Care
Cataract	Gradual, painless blurred or cloudy vision; glare; halos	Surgery (lens replacement). After: eye shield at night; avoid bending, heavy lifting, straining and rubbing the eye; eye drops; report sudden pain or vision loss
Open-angle glaucoma	Painless, gradual loss of side vision ("tunnel vision")	Lifelong drops: latanoprost (can darken iris), timolol (can slow HR, cause bronchospasm), others. Press the inner corner of the eye 1–2 min after drops
Angle-closure glaucoma	Sudden severe eye pain, headache, nausea, red eye, halos, fixed mid-dilated pupil	Emergency: drops and IV meds to lower pressure, then laser surgery. Avoid anticholinergics (atropine, diphenhydramine) in at-risk patients
Macular degeneration	Loss of central vision	Dry: AREDS2 vitamins; Wet: anti-VEGF eye injections. Home Amsler grid checks
Retinal detachment	Flashes, floaters, a curtain or shadow over vision	Emergency surgery. Afterwards, position as the surgeon orders (e.g., face-down with a gas bubble); no flying or high altitude while gas is present

Eye emergencies and drops

Chemical splash: flush immediately with water or saline for at least 15 min, before anything else.
Penetrating object: don't remove it; protect with a rigid shield (no pressure); keep the patient still.
Giving drops: pull down the lower lid, drop into the pocket, don't touch the eye; wait ~5 min between different drops; drops before ointments.

Ears and balance

Hearing loss: conductive (outer/middle ear) vs. sensorineural (inner ear, nerve). Face the person, speak clearly in a lower pitch; don't shout.
Ear irrigation: body-temperature fluid; adults: pull the outer ear up and back; children <3: down and back. Not if the eardrum may be perforated.
Ménière's disease: attacks of vertigo, ringing (tinnitus), fullness, hearing loss. Low-sodium diet, limit caffeine and alcohol, meclizine; lie still during attacks; fall precautions.
Ototoxic drugs: aminoglycosides, loop diuretics (fast IV), cisplatin, high-dose aspirin, vancomycin.

Shock and Sepsis

Types of shock and the Surviving Sepsis Campaign hour-1 bundle

Med-Surg · Critical Care

Types of shock

Type	Cause	Clues	Main treatment
Hypovolemic	Bleeding, dehydration, burns	Tachycardia, cool clammy skin, flat neck veins, ↓ urine	Stop the bleeding; fluids, blood
Cardiogenic	Pump failure (MI, HF)	Crackles, JVD, ↓ BP, cool skin	Inotropes, revascularization; careful fluids
Septic (distributive)	Infection → vasodilation	Fever or low temp, warm or mottled skin, ↑ lactate	Antibiotics, fluids, norepinephrine
Anaphylactic (distributive)	Allergic reaction	Hives, wheeze, swelling	IM epinephrine, fluids
Neurogenic (distributive)	Spinal cord injury T6 or above	↓ BP with bradycardia, warm dry skin	Fluids, vasopressors, atropine
Obstructive	Tension pneumothorax, tamponade, massive PE	JVD, ↓ BP; tracheal shift or muffled heart sounds	Relieve the obstruction

Early shock: restlessness, tachycardia, fast breathing, ↓ urine output, cool skin; BP may still be normal. Hypotension is a late sign.

Sepsis

Sepsis = life-threatening organ dysfunction caused by the body's response to infection. Septic shock = needs vasopressors to keep MAP ≥65 and lactate >2 despite fluids.

Look for: fever or hypothermia, tachycardia, tachypnea, confusion, low BP, mottled skin, low urine output. Older adults may only seem confused or weak.

qSOFA should not be used alone to screen for sepsis. Updated

Hour-1 bundle (Surviving Sepsis Campaign)

Measure lactate; remeasure if >2 mmol/L.
Blood cultures before antibiotics (without delaying them).
Broad-spectrum antibiotics: within 1 hour for septic shock or probable sepsis.
30 mL/kg crystalloid (balanced solutions such as LR preferred) for hypotension or lactate ≥4.
Norepinephrine if MAP stays <65 during or after fluids.

Then: source control, urine output ≥0.5 mL/kg/h, glucose 140–180, reassess fluid status often.

Priority A patient with infection who becomes newly confused, breathes fast and has a falling BP: call the rapid response team. Every hour of delay in antibiotics for septic shock raises the risk of death.

Therapeutic Communication

What helps, what blocks, and defense mechanisms

Mental Health

Therapeutic techniques

Open-ended questions	"What has been on your mind today?"
Broad openings	"Where would you like to start?"
Restating / reflecting	"You feel angry that no one visits."
Clarifying	"I'm not sure I follow. Can you tell me more?"
Focusing	"Let's talk more about the argument."
Offering self	"I'll sit with you for a while."
Silence	Gives time to think and feel
Presenting reality	"I don't hear voices, but I can see you're frightened."
Summarizing	"Today we talked about…"

Communication blocks (avoid)

False reassurance	"Don't worry, everything will be fine."
Asking "why"	"Why did you do that?" (sounds judgmental)
Giving advice	"If I were you, I'd…"
Approval / disapproval	"That's good." / "You shouldn't feel that way."
Changing the subject	Moving away from the patient's feelings
Minimizing	"Everyone feels that way sometimes."
Defending	"The doctor is very good; she wouldn't do that."
Closed or yes/no questions	Use only when you need specific facts (e.g., suicide risk)

On exams, the best answer usually acknowledges feelings and invites the patient to say more.

The nurse–patient relationship (Peplau)

Orientation: build trust, set the contract (time, purpose), explain confidentiality and its limits (danger to self or others), plan for the ending.
Working: explore problems, practice coping skills.
Termination: review progress, discuss feelings about ending. Begin preparing from day one.
Boundaries: no personal relationships, gifts, or sharing personal problems; therapeutic self-disclosure only if it helps the patient.

Defense mechanisms

Denial	Refusing to accept reality
Projection	Blaming others for your own feelings
Displacement	Taking feelings out on a safer target
Rationalization	Giving acceptable excuses
Regression	Returning to earlier behavior
Repression / suppression	Unconscious / conscious pushing away of thoughts
Reaction formation	Acting the opposite of what you feel
Sublimation	Channeling impulses into acceptable activity (healthy)
Intellectualization	Focusing on facts to avoid feelings

Memory hook Suppression is sure (conscious, chosen). Repression is removed from awareness (unconscious). Displacement: the boss yells at you, you yell at the dog.

Anxiety, OCD and Trauma Disorders

Levels of anxiety and nursing care

Mental Health

Levels of anxiety

Level	What you see	Nursing approach
Mild	Alert, sharper focus; learning is easy	Teach, problem-solve
Moderate	Narrower focus; can learn with direction; some physical symptoms	Guide; help focus
Severe	Very narrow focus; can't learn or solve problems; headache, nausea, trembling	Calm, simple directions; reduce stimuli
Panic	Can't think or communicate clearly; may be a danger to self	Stay with the patient, short simple sentences, quiet room, safety, PRN medication. Teach later

Anxiety disorders

Generalized anxiety disorder: excessive worry on most days for ≥6 months. CBT; SSRIs/SNRIs; buspirone.
Panic disorder: sudden attacks peaking within minutes (chest pain, pounding heart, fear of dying) + worry about future attacks. Rule out medical causes first. CBT, SSRIs; benzodiazepines short-term only.
Phobias and social anxiety: gradual exposure therapy.
Coping: slow breathing, grounding, muscle relaxation, exercise, limiting caffeine.

Obsessive-compulsive disorder

Obsessions (intrusive thoughts) → compulsions (rituals) that reduce anxiety for a while.
Don't stop rituals abruptly at first (anxiety will spike): allow time, build a schedule, then gradually limit.
Exposure and response prevention (therapy); SSRIs (often higher doses), clomipramine.
Watch skin (handwashing), nutrition, sleep.

PTSD

After trauma, lasting >1 month: intrusions (flashbacks, nightmares), avoidance, negative mood and thoughts, hyperarousal (startle, irritability, poor sleep). (3 days–1 month = acute stress disorder.)
Trauma-focused therapy (prolonged exposure, cognitive processing, EMDR); SSRIs (sertraline, paroxetine) or venlafaxine.
Screen for substance use and suicide risk.

Trauma-informed care

Assume anyone may have trauma history: explain before touching, offer choices and control, provide privacy, avoid re-traumatizing procedures and restraints, stay calm and predictable.

Somatic and functional disorders

Somatic symptom disorder: real distress focused on physical symptoms. Functional neurological disorder (formerly "conversion disorder"): genuine neurologic symptoms (weakness, seizures) without structural disease. The patient isn't faking: acknowledge symptoms, focus on function, avoid unneeded tests.

Depression and Suicide Prevention

Recognizing depression, treatment options, and assessing suicide risk

Mental Health

Major depressive disorder

≥5 symptoms for ≥2 weeks, including depressed mood or loss of interest:

Memory hook: SIG E CAPS Sleep change · Interest lost · Guilt or worthlessness · Energy low · Concentration poor · Appetite or weight change · Psychomotor slowing or agitation · Suicidal thoughts.

Screen with PHQ-9. Rule out thyroid disease, anemia, medications, substance use. Older adults may show memory problems or physical complaints.

Treatment

Psychotherapy (CBT and others) + antidepressants (4–6 weeks for full effect).
ECT: severe, psychotic or treatment-resistant depression, or high suicide risk. Consent; NPO; anesthesia and a muscle relaxant. Afterwards: brief confusion, headache, short-term memory loss; reorient, safety.
Esketamine nasal spray (treatment-resistant): observe ≥2 h in a certified setting (dissociation, sedation, ↑ BP); no driving that day.
Transcranial magnetic stimulation; bright light therapy (seasonal pattern).
Postpartum depression: zuranolone (oral, 14 days). Brexanolone IV was withdrawn from the US market in 2025. Updated

Suicide risk

Ask directly

"Are you thinking about killing yourself?" Asking does not put the idea in someone's head. Then: plan? method? access (especially firearms)? timing? intent? Use a tool such as the Columbia scale (C-SSRS).

Risk factors

Previous attempt (strongest), a specific plan with access to means, depression, substance use, men, older adults, LGBTQ+ youth, chronic pain or illness, recent loss, isolation, recent psychiatric discharge.

Warning signs

Giving away possessions, saying goodbye, writing a will, sudden calm or improvement after severe depression (may have decided on a plan, or now has energy to act).

Nursing actions

High risk: 1:1 continuous observation, within arm's reach as ordered.
Remove dangerous items (belts, cords, sharps, plastic bags, glass); search belongings per policy.
Check that oral medications are swallowed (no "cheeking").
Safety plan together: warning signs, coping steps, people to contact, removing access to means. No-suicide contracts are not effective: don't rely on them. Updated
Crisis line: call or text 988 (Suicide & Crisis Lifeline).

Priority A patient who says "I won't be a problem much longer" or "It doesn't matter now" needs a direct question about suicide right away, not reassurance or a change of subject.

Bipolar Disorder

Mania, hypomania and depression

Mental Health

Types

Bipolar I	At least one manic episode (≥7 days, or any length if hospitalized); depression common
Bipolar II	Hypomania (≥4 days, no psychosis, no hospitalization) + major depression
Cyclothymia	Milder ups and downs for ≥2 years

Signs of mania

Elevated or irritable mood, grandiosity, little need for sleep, pressured speech, flight of ideas, distractibility, hyperactivity, risky behavior (spending, sex, driving), possible psychosis.

Nursing care in mania

Safety first (exhaustion, injury, aggression).
Low-stimulation environment: quiet room, few visitors, avoid group and competitive activities.
Calm, firm, consistent limits; short, simple statements; don't argue or debate.
High-calorie finger foods and fluids they can eat while moving (sandwiches, shakes).
Channel energy into solitary physical activity (walking, writing).
Promote rest and sleep; monitor weight, intake, hydration.

Medications

Lithium (level 0.6–1.2 mEq/L; see Part 1 for toxicity and teaching).
Valproate, carbamazepine; lamotrigine (prevents depressive episodes).
Second-generation antipsychotics (quetiapine, olanzapine, aripiprazole, lurasidone, cariprazine).
Antidepressants alone can trigger mania: used only with a mood stabilizer, if at all.

Teaching

Take medication even when feeling well (stopping is the top cause of relapse).
Regular sleep schedule: sleep loss can trigger mania.
Learn early warning signs (less sleep, racing thoughts, spending).
Avoid alcohol and drugs; family education; support groups.

Memory hook Flight of ideas (rapid jumping between related topics) is a sign of mania. Loose associations (unrelated jumps) point to schizophrenia.

Schizophrenia and Psychosis

Symptoms, responding to hallucinations and delusions, and treatment

Mental Health

Symptoms

Positive (added): hallucinations (usually voices), delusions, disorganized speech and behavior.
Negative (taken away): flat affect, little speech (alogia), low motivation (avolition), no pleasure (anhedonia), social withdrawal.
Cognitive: poor attention, memory and planning.
Duration ≥6 months (with ≥1 month of active symptoms).

Disorganized speech

Loose associations, word salad, clang associations (rhyming), neologisms (made-up words), echolalia (repeating), concrete thinking.

Delusions

Persecutory	"They're poisoning me." (offer sealed or packaged food)
Grandiose	"I'm the president's advisor."
Referential	"The TV is sending me messages."
Somatic	"My organs are rotting."

Don't argue or try to prove it wrong, and don't pretend to agree. Respond to the feeling, focus on reality and present activities, build trust.

Responding to hallucinations

Watch for cues: looking around, talking or laughing to no one, tilting the head as if listening.
Ask what the voices are saying: command hallucinations telling the person to harm themselves or others are an emergency for safety.
Present reality without arguing: "I don't hear the voices, but I can see they're upsetting you."

Focus on what's real right now; engage in a simple activity; distraction (music, conversation).
Reduce noise and stimulation.
Teach coping: humming, talking back to voices in a firm way, telling staff.

Treatment

Antipsychotics (see Part 1): adherence is key; long-acting injections help.
Clozapine for treatment-resistant illness and suicidal behavior (ANC monitoring).
Metabolic monitoring (weight, glucose, lipids).
Family psychoeducation, social skills training, supported employment, case management.

Related conditions

Schizoaffective: psychosis + major mood episodes.
Delusional disorder: fixed delusions, otherwise functioning.
Brief psychotic disorder: ≥1 day but <1 month, with full return to baseline.
Catatonia: immobility, mutism, posturing → lorazepam, ECT; watch nutrition and skin.

Substance Use and Withdrawal

Alcohol, opioids, stimulants and nicotine

Mental Health

Alcohol withdrawal timeline (after the last drink)

Time	What happens
6–24 h	Tremor, anxiety, sweating, nausea, insomnia, tachycardia and hypertension
12–48 h	Hallucinations (usually with clear consciousness)
6–48 h	Seizures (peak ~24 h)
48–96 h	Delirium tremens: confusion, hallucinations, fever, severe autonomic instability. Can be fatal

Use CIWA-Ar to score severity; give benzodiazepines (chlordiazepoxide, diazepam, or lorazepam in liver disease) per protocol. Thiamine before glucose (prevents Wernicke's encephalopathy: confusion, ataxia, eye movement problems → Korsakoff: memory loss, confabulation). Seizure precautions; quiet, well-lit room; fluids and electrolytes (Mg²⁺, K⁺).

Alcohol use disorder: long term

Naltrexone (reduces cravings; not with opioids; liver tests).
Acamprosate (start after withdrawal; adjust for kidneys).
Disulfiram: any alcohol (including mouthwash, cough syrup, some sauces) → flushing, vomiting, low BP. Only for motivated patients.
Mutual support (AA), motivational interviewing; screen with AUDIT; SBIRT.

Opioids

Overdose: pinpoint pupils, slow breathing, unresponsive → naloxone (available over the counter), rescue breaths/CPR. Fentanyl may need repeat doses; naloxone is still given when xylazine may be present (xylazine also causes sedation and wounds).
Withdrawal (rarely fatal in adults): yawning, runny nose, tearing, dilated pupils, gooseflesh, cramps, diarrhea, vomiting, anxiety. Score with COWS.
Medications for opioid use disorder: buprenorphine (start once in withdrawal, or it triggers sudden withdrawal; any DEA-registered prescriber since 2023), methadone (clinic; QT), naltrexone (after 7–10 days opioid-free).

Stimulants (cocaine, methamphetamine)

Intoxication: high BP and HR, hyperthermia, chest pain (MI), paranoia, agitation, seizures → benzodiazepines, cooling. Withdrawal ("crash"): exhaustion, oversleeping, hunger, depression and suicide risk, cravings.

Cannabis

Heavy use can cause cannabinoid hyperemesis syndrome: cyclic vomiting relieved by hot showers.

Nicotine

Combine counseling with medication: varenicline (most effective), nicotine replacement (patch + short-acting form), bupropion. Ask every patient about tobacco and vaping.

Memory hookOpioid overdose = pupils pinpoint. Opioid withdrawal = pupils wide and everything running (nose, eyes, gut).

Eating and Personality Disorders

Medical risks in eating disorders, and approaches for personality disorders

Mental Health

	Anorexia nervosa	Bulimia nervosa	Binge-eating disorder
Pattern	Restriction, low weight, intense fear of weight gain, distorted body image	Binges + purging (vomiting, laxatives, exercise); often normal weight	Binges without purging; distress, shame
Physical signs	Bradycardia, hypotension, low temperature, lanugo, missed periods, bone loss, low K⁺	Low K⁺, metabolic alkalosis, dental erosion, swollen parotid glands, knuckle calluses (Russell's sign), dysrhythmias	Weight gain, metabolic problems
Medications	No approved drug; treat nutrition first	Fluoxetine (FDA-approved). Bupropion is contraindicated (seizures)	Lisdexamfetamine (FDA-approved); CBT

Nursing in eating disorders

Refeeding syndrome: as feeding restarts, phosphate, K⁺ and Mg²⁺ can crash → heart failure, dysrhythmias. Start slowly; check electrolytes daily at first.
Supervise meals and observe for ~1 hour afterward (purging); bathroom access supervised as ordered.
Weigh at the same time, same scale, in a gown, often with the patient facing away.
Focus on feelings and control issues, not food; consistent team approach; family-based therapy for teens.
Cardiac monitoring if electrolytes are abnormal.

Personality disorder clusters

A: odd, eccentric	Paranoid, schizoid, schizotypal
B: dramatic, emotional	Antisocial, borderline, histrionic, narcissistic
C: anxious, fearful	Avoidant, dependent, obsessive-compulsive personality

Borderline personality disorder

Unstable relationships and mood, fear of abandonment, impulsivity, self-harm, splitting (people are all good or all bad). DBT is the main therapy. Safety first; clear, consistent limits; the whole team uses the same approach (prevents splitting).

Antisocial personality disorder

Disregard for others' rights, manipulation, lack of remorse, rule-breaking. Set firm, consistent limits with clear consequences; don't accept flattery or bargaining; focus on behavior, not explanations.

Crisis, Aggression, Abuse and Legal Issues

Safety, patient rights and reporting

Mental Health

Preventing and managing aggression

Early signs: pacing, clenched fists, loud voice, staring, threats.
De-escalate: calm low voice, respect personal space, open posture, offer choices, listen, reduce stimuli.
Your safety: keep a clear path to the door; don't turn your back; get help early.
PRN medication offered voluntarily first.
Seclusion or restraint only for imminent danger when other steps fail: order required; violent-behavior orders last up to 4 h (adults), 2 h (ages 9–17), 1 h (under 9); face-to-face evaluation within 1 h; continuous monitoring.

Admission and patient rights

Voluntary: may request discharge (may be held briefly for evaluation, per state law).
Involuntary: danger to self or others, or gravely disabled; time limits and court review per state law.
Patients keep their rights: to communicate, to have visitors, privacy, the least restrictive care, and to refuse treatment (except in emergencies or by court order). Commitment doesn't mean legal incompetence.
Duty to warn (Tarasoff): credible threats against an identifiable person must be reported per policy.

Abuse and violence

Intimate partner violence

Ask privately, without the partner present; use a professional interpreter, not family.
Cycle: tension building → violent incident → "honeymoon" (apology, calm).
Safety planning; document injuries with photos, body maps and the patient's own words; give resources. Reporting rules for adults vary by state.

Sexual assault

Ideally, don't shower, change, or urinate before the exam (evidence).
Forensic nurse (SANE) exam; emergency contraception; STI prophylaxis; HIV PEP within 72 h; emotional support.

Child abuse: red flags (mandatory report)

Injuries that don't match the story or developmental stage; delay in seeking care.
Bruises on a baby who isn't yet cruising; patterned bruises; bruises on ears, neck, torso.
Spiral fractures, multiple fractures at different stages; immersion burns (glove or stocking pattern).

Older adult abuse (mandatory report)

Unexplained injuries, poor hygiene, missing money or possessions, fear of a caregiver, untreated problems.

Human trafficking signs: someone else speaks for the patient, holds their ID, inconsistent stories.

Crisis intervention

A crisis is short-term (usually resolves within 4–6 weeks). Be directive, focus on the immediate problem and safety, mobilize supports and coping skills, then plan follow-up.

Grief

Kübler-Ross stages (denial, anger, bargaining, depression, acceptance) don't happen in a fixed order. Prolonged grief disorder (new diagnosis): intense grief lasting ≥12 months (≥6 months in children) that disrupts life.

Delirium, Dementia and Neurodevelopmental Disorders

Telling them apart, and caring for cognition

Mental Health

	Delirium	Dementia	Depression
Onset	Sudden (hours to days)	Gradual (months to years)	Weeks to months
Course	Fluctuates, often worse at night	Slowly progressive	Can improve with treatment
Attention	Impaired	Normal early	Poor effort ("I don't know")
Reversible?	Usually, if the cause is treated	No	Yes

Delirium is a medical emergency. Screen with the CAM (Confusion Assessment Method).

Delirium: find the cause

Infection (UTI, pneumonia), medications (anticholinergics, benzodiazepines, opioids), dehydration, low oxygen, pain, urinary retention, constipation, sleep loss, alcohol withdrawal, electrolyte imbalance.
Prevent and manage: reorientation, glasses and hearing aids, day–night routine, early mobility, family presence, hydration, avoid restraints and benzodiazepines (except alcohol withdrawal).
Antipsychotics only for severe agitation or danger, short-term.

Dementia care (e.g., Alzheimer's)

Consistent routine and caregivers; simple one-step instructions; limited choices.
Don't argue or "quiz"; validate feelings and redirect.
Wandering: door alarms, ID bracelet, secure unit. Sundowning: light during the day, activity, calm evenings.
Label rooms; remove hazards; supervise meals and medications.
Support caregivers (respite, resources).
Antipsychotics carry a boxed warning: higher risk of death in older adults with dementia.

ADHD

Inattention and/or hyperactivity-impulsivity starting before age 12, in 2 or more settings (home, school). Behavior therapy (first for preschoolers), classroom supports, stimulants or non-stimulants (see Part 1). Consistent rules, short instructions, praise.

Autism spectrum disorder

Differences in social communication + restricted, repetitive behaviors or interests. Screen at 18 and 24 months (M-CHAT). In the hospital: keep routines, warn ahead of changes, reduce noise and light, use visual supports, involve parents, minimize waiting.

Conversions and Rounding

The numbers you need memorized, and three ways to set up any problem

Dosage Calculation

Metric

1 kg	= 1,000 g
1 g	= 1,000 mg
1 mg	= 1,000 mcg
1 L	= 1,000 mL
1 mL	= 1 cc (write "mL", not "cc")

Moving down a step (bigger unit → smaller unit): × 1,000. Moving up: ÷ 1,000.

Household and weight

1 kg	= 2.2 lb
1 lb	= 16 oz
1 in	= 2.54 cm
1 tsp	= 5 mL
1 tbsp	= 15 mL (3 tsp)
1 fl oz	= 30 mL
1 cup	= 240 mL (8 oz)

Temperature

°F = (°C × 9/5) + 32

°C = (°F − 32) × 5/9

Check yourself: 37°C = 98.6°F; 38°C = 100.4°F.

Rounding rules (common exam rules)

Round only the final answer, not each step.
Volumes >1 mL: nearest tenth (2.46 → 2.5 mL).
Volumes <1 mL: nearest hundredth (0.756 → 0.76 mL): use a 1 mL syringe.
Tablets: whole, or half only if scored.
Drops per minute: whole number. Weight in kg: nearest tenth.
Always a leading zero (0.5 mg); never a trailing zero (5 mg, not 5.0 mg).
Follow any rounding instruction in the question.

Three ways to set up a problem

Example: order amoxicillin 500 mg; available 250 mg per 5 mL.

Formula

Desired ÷ Have × Quantity
500 ÷ 250 × 5 mL = 10 mL

Ratio–proportion

250 mg : 5 mL = 500 mg : x mL
250x = 2,500 → x = 10 mL

Dimensional analysis

500 mg × (5 mL ÷ 250 mg) = 10 mL
Units you don't want cancel out.

Pick one method and use it every time. Check the units first: convert the order and the supply to the same unit before calculating.

Practice

154 lb = ___ kg
0.25 mg = ___ mcg
38.5°C = ___ °F
102.2°F = ___ °C
2 tbsp = ___ mL

Answers

154 ÷ 2.2 = 70 kg
0.25 × 1,000 = 250 mcg
38.5 × 9/5 + 32 = 101.3°F
(102.2 − 32) × 5/9 = 39°C
2 × 15 = 30 mL

Oral and Injectable Doses

Tablets, liquids, injections and weight-based doses

Dosage Calculation

Worked examples

Order	Available	Setup	Answer
Metoprolol 50 mg PO	25 mg tablets	50 ÷ 25 × 1	2 tablets
Levothyroxine 0.1 mg PO	50 mcg tablets	0.1 mg = 100 mcg; 100 ÷ 50	2 tablets
Amoxicillin 500 mg PO	250 mg/5 mL	500 ÷ 250 × 5	10 mL
Heparin 5,000 units SC	10,000 units/mL	5,000 ÷ 10,000 × 1	0.5 mL
Morphine 3 mg IV	4 mg/mL	3 ÷ 4 × 1	0.75 mL
Furosemide 40 mg IV	10 mg/mL	40 ÷ 10 × 1	4 mL
Enoxaparin 1 mg/kg SC, patient 80 kg	100 mg/mL	80 mg ÷ 100 × 1	0.8 mL

Weight-based doses: steps

Convert weight to kg (lb ÷ 2.2).
Multiply by the ordered mg/kg → dose.
Check whether the order is per dose or per day (divide daily doses by the number of doses).
Convert the dose to volume or tablets.

Example: vancomycin 15 mg/kg IV, patient 154 lb → 70 kg × 15 = 1,050 mg.

Reconstituting powders

Read the label: which diluent and how much.
Note the resulting concentration (e.g., "adding 4.8 mL gives 100 mg/mL").
Label multi-dose vials with date, time, concentration and your initials.

Example: vial makes 100 mg/mL; order 250 mg → 250 ÷ 100 = 2.5 mL.

Injection basics

Route	Angle	Needle (adult, typical)	Notes
Intradermal	10–15°	25–27 G, ⅜–⅝ in	Forms a bleb (TB skin test); don't massage
Subcutaneous	45–90°	25–30 G, ⅜–⅝ in	45° if little fat; insulin and heparin: don't massage; don't aspirate
Intramuscular	90°	22–25 G, 1–1½ in	Ventrogluteal preferred site for larger volumes (up to ~3 mL); deltoid ≤1 mL; vastus lateralis for infants

Z-track (irritating drugs): pull skin aside, inject, wait 10 sec, release. Insulin: use a U-100 insulin syringe; dose in units (no calculation of mL needed).

Priority An answer that seems odd (e.g., 8 tablets, or 15 mL for an IV push) usually means a unit error. Recheck before giving, and ask a second nurse to double-check high-alert drugs.

IV Flow Rates and Infusions

mL/h, drops per minute, infusion times and dose-based drips

Dosage Calculation

Formulas

Pump rate	mL/h = total mL ÷ hours
Gravity drip	gtt/min = (mL × drop factor) ÷ minutes
Infusion time	hours = total mL ÷ mL/h
Dose-based	mL/h = dose per hour ÷ concentration

Drop factors: macrodrip 10, 15 or 20 gtt/mL; microdrip 60 gtt/mL (with microdrip, gtt/min = mL/h).

Concentration

Concentration = amount of drug ÷ volume of the bag.

Heparin 25,000 units in 250 mL = 100 units/mL.
Heparin 25,000 units in 500 mL = 50 units/mL.
Dopamine 400 mg in 250 mL = 1.6 mg/mL = 1,600 mcg/mL.

Worked examples

Problem	Setup	Answer
1,000 mL NS over 8 h (pump)	1,000 ÷ 8	125 mL/h
1,000 mL over 8 h, drop factor 15	(1,000 × 15) ÷ 480 = 31.25	31 gtt/min
500 mL over 4 h, drop factor 20	(500 × 20) ÷ 240 = 41.67	42 gtt/min
Antibiotic 100 mL over 30 min (pump)	100 ÷ 0.5 h	200 mL/h
1,000 mL at 125 mL/h, started 0800	1,000 ÷ 125 = 8 h	Finishes 1600
Heparin 1,000 units/h; bag 25,000 units/250 mL	1,000 ÷ 100 units/mL	10 mL/h
Pump at 20 mL/h; heparin 25,000 units/500 mL. Dose?	20 mL/h × 50 units/mL	1,000 units/h
Dopamine 5 mcg/kg/min, 80 kg; bag 400 mg/250 mL	5 × 80 = 400 mcg/min × 60 = 24,000 mcg/h ÷ 1,600 mcg/mL	15 mL/h
KCl 20 mEq in 100 mL over 2 h	100 ÷ 2; 20 ÷ 2	50 mL/h (10 mEq/h)

Weight-based heparin (example protocol)

Patient 80 kg. Bolus 80 units/kg = 6,400 units. Infusion 18 units/kg/h = 1,440 units/h. Bag 100 units/mL → 1,440 ÷ 100 = 14.4 mL/h. Then adjust by aPTT or anti-Xa per your facility's protocol.

Check your answer

Does it make sense? A maintenance IV is usually 75–150 mL/h in adults.
Minutes vs. hours is the most common mistake in drip problems (× 60 to go from per minute to per hour).
mcg vs. mg is the second most common: convert first.

Pediatric Doses and Other Calculations

Safe dose ranges, body surface area, maintenance fluids and intake and output

Dosage Calculation

Is the ordered dose safe? (4 steps)

Weight in kg.
Calculate the safe range from the reference (mg/kg/day or mg/kg/dose).
Calculate what the order gives (per dose or per day: compare like with like).
Inside the range → calculate the volume. Outside → hold the dose and call the prescriber.

Worked examples

Problem	Working	Result
Amoxicillin 200 mg PO every 12 h. Child 22 lb. Safe: 25–45 mg/kg/day. Supply 400 mg/5 mL	22 ÷ 2.2 = 10 kg → safe 250–450 mg/day. Order = 400 mg/day → safe. 200 ÷ 400 × 5	2.5 mL per dose
Acetaminophen 240 mg PO every 6 h. Child 18 kg. Max 15 mg/kg/dose. Supply 160 mg/5 mL	Max 270 mg/dose → safe. 240 ÷ 160 × 5	7.5 mL
Cefazolin 500 mg IV every 8 h. Child 12 kg. Safe: 25–100 mg/kg/day	Safe 300–1,200 mg/day. Order = 1,500 mg/day	Unsafe: hold and clarify

Body surface area (Mosteller)

BSA (m²) = √(height cm × weight kg ÷ 3,600)

Example: 150 cm, 45 kg → √(6,750 ÷ 3,600) = √1.875 = 1.37 m². Used for chemotherapy and some pediatric doses.

Maintenance fluids (Holliday-Segar)

100 mL/kg/day (first 10 kg) + 50 mL/kg/day (next 10 kg) + 20 mL/kg/day (each kg above 20).
Example: 15 kg → 1,000 + 250 = 1,250 mL/day ≈ 52 mL/h.

Intake and output

Intake: oral fluids, IV fluids and flushes, tube feeds and water flushes, irrigant not returned, and foods liquid at room temperature (gelatin, ice cream, popsicles, soup). Ice chips ≈ half their volume as water.
Output: urine, emesis, diarrhea, drains, NG output, wound drainage.

Example: milk 240 mL + juice 120 mL + IV 100 mL/h × 8 h (800 mL) + ice chips 200 mL (= 100 mL) → intake 1,260 mL. Urine 650 + 400 mL + emesis 150 mL → output 1,200 mL.

Memory hook "Per day ÷ doses per day = per dose." Many pediatric errors happen when a daily dose is given as each dose.