NCLEX Study Guide

[altafpatel]

Abdominal Pain Differential Diagnosis (Dx) according to different regions

[dieselotherapy]

Skill: assessing pupil response.

Lets look a little closer at this particular skill.

First up, the pupil isn’t actually anything at all. A hole at the centre of the iris that controls the amount of light entering the eye. The size of this hole is controlled by 2 muscles within the iris. The pupilloconstrictor (controlled by the parasympathetic nervous system) and the pupillodilator (controlled by the sympathetic nervous system). So I guess what we are really assessing here is the iris response.

Pupil contraction (parasympathetic response):

When a light intensity increases across the rods and cones of the retina, impulses travel via the optic nerve to the pretectal nucleus of the upper midbrain.

From here impulses travel to the Edinger-Westphal nucleus, and onwards via the III cranial nerve (occulomotor) to the pupilloconstrictor muscle of the iris… causing contraction (miosis).

Pupil dilation (sympathetic response):

When light intensity decreases, impulses travel from the retina via the optic nerve to neurones on the hypothalamus where it takes a convoluted neuronal journey through the lateral brainstem to the spinal cord, down across the apex of the lung, back up alongside the internal carotid into the skull, through the inferior orbital fissure. Finally, it travels along the V cranial nerve (trigeminal) that innervates the pupillodilator muscle of iris… causing dilation (mydriasis).

How to assess pupillary reflexes.

Ideally, pupillary reflexes should be examined in a dim environment. If the patient is conscious, ask them to fix their gaze on a target some distance behind you ( If they re-focus on you or your torch, there may be pupil constriction as a result of accomodation).

Use a neurotorch or cheap penlight torch. This is for 2 reasons:

Using a superbright concentrated light will not be appreciated by a conscious patient.

Doctors do not (as a rule) carry neuro torches. They borrow the nurses. They forget to give them back.

Size and Equality.

The pupil size is documented as the diameter in millimetres. Tools to help you estimate this size include pupil gauges located on most Glasgow Coma Scale records and many neuro torches.

You may also find it useful in your written documentation to include descriptors such as: pinpoint, small, midposition, large, dilated.

Aniscoria: Up to 20% of the population have a slight difference in pupil size and is considered a normal variant. This difference should not be greater than 1mm and pupil reactivity should be normal.

Shape:

The pupil shape can be documented as round, irregular, oval or keyhole. Causes of irregular pupils include cataract surgery or the implantation of intra-occular lenses.

Oval pupils may be a result of compression of the III cranial nerve as a result of raised intracranial pressure (ICP). As ICP increases, the pupil will continue to dilate and eventually become non-reactive to light.

Keyhole pupils are seen in patients post iridectomy (a common part of cataract surgery). They may still react to light but usually the reactivity is sluggish.

Reactivity:

The pupil response to light is assessed by shining a neuro torch (or low powered penlight torch) separately into each eye. Tip: shining the torch onto the pupil from directly above may make assessment difficult due to ‘glare’ reflected off the cornea. Instead, position yourself in front of the eye and shine the beam from slightly off to one side.

Document pupil reactivity to light separately. Reactivity may be:

Brisk

Sluggish

Non-reactive.

At the same time look for the normal pupillary constriction response in the opposite eye. This is called the consensual pupillary response.

Accommodation:

This is the normal constriction of the pupil that occurs when a conscious patient is asked to shift their focus from a distant object, to a close one.

Causes of abnormal pupils:

Unequal pupils:

Mydriasis: One pupil is dilated and non-reactive whilst the other is normal. May be caused by compression of the III cranial nerve, compression of the posterior communicating artery or by direct damage to the nerve endings in the iris sphincter muscle.

Following a traumatic brain injury an increase in intracranial pressure can lead to the uncus (part of the temporal lobe) squeezing against the tentorium and pressing against the III cranial nerve resulting in a dilated pupil (mydriasis) on the affected (ipsilateral) side. If pressure continues to increase, contralateral dilation will also occur.

Horner’s Syndrome: One pupil is smaller than the other and has a decreased response to light and accommodation. There is ptosis of the eyelid on the affected side. Caused by loss of sympathetic intervention to the pupil due to a lesion in the brainstem of spinal cord, or damage to the hypothalamus. There is also decreased sweating (Anhidrosis) of some or all of the face. Causes of Horner’s syndrome include carotid artery dissection, nasopharyngeal tumours, brachial plexus injury.

Dilated pupils:

Drug induced mydriasis: bilateral dilation as a result of drugs including antihistamines, hallucinogens, amphetamines, anticholinergics, dopamine or barbiturates. May be caused by medication used for ophthalmic examination such as atropine, scopolamine, or by anoxia or brain death.

Mental or emotional stimulation: Dilation may also be caused by sexual arousal or increased mental effort.

Constricted pupils

Miosis: Bilateral pinpoint pupils (usually too small to figure out if they are responding to light or not). May be caused by disruption to the sympathetic pathway due to intraocular inflammation or direct trauma, a pontine haemorrhage, or due to the effect of drugs such as opiates, pilocarpine or acetylcholine.

Equal pupils:

Hippus: Initially react to light but then alternate between dilated and constricted. May indicate early compression of III cranial nerve. May indicate injury to the midbrain or barbiturate toxicity.

Relative Afferent Pupillary Defect (RAPD): When light is shone into the effected eye there is a sluggish reaction. There is a normal consensual reaction when light is shone into the opposite eye, but when the light is quickly shone back to the effected eye it will dilate. This is known as the swinging flashlight test (see video below) and may indicate optic neuritis, retinal detachment or infection or direct optic nerve damage.

In conclusion, a pupil assessment is a quick but important skill that can give a great deal of information. The eyes may indeed be the windows to the soul. But the pupils are the manholes to the ongoing neurological status of your patient.

(x)

[secretlifeofateenblogger-blog]

I keep forgetting what the differences are in the over the counter pain relievers, so I made a handy chart.

[androfembot-deactivated20220204]

so. beautiful.

[ob-nurse--at-your-cervix]

Tylenol arthritis was actually effective for treating migraines for me. For several years I could only take Tylenol for pain relief because I had been prescribed a medication that was highly toxic to the kidneys.

[biomedicalephemera]

Splanchnology - The study or discourse of the viscera (guts) - Greek: Splanchn(o), “viscera”.

Stomach (organ) - From Latin stomachus, “throat, gullet, stomach” [also “pride, indignation”, since those emotions were believed to arise from the stomach]. Derived from Greek stomachos, “throat, stomach”, literally an extension of stoma, "mouth, opening" Pertaining to the stomach - Gastr(o)-, Ventr(o)- Abdomen - “Belly fat”, from Latin abdomen, meaning, well, what it does today. Ultimate origin of the word is unknown. Pertaining to the abdomen - Laparo-, Abdomin(o)-, Ventr(o)-

Digestion - From Latin dis-, “apart”, gerere, “to carry”, “to assimilate food in the bowels” Pertaining to digestion - -pepsia

Lungs - From Old English lungen, from Proto-Germanic *lungw-, literally “the light organ”, legwh-, “not heavy, having little weight”. Probably from the fact that lungs float when put in water (and other organs do not). Pertaining to the lungs - Pulmo-, Pneumo-

Liver - From Proto-Indo-European (PIE) *liep-, “to stick, adhere, fat” Pertaining to the liver - Hepat(o)-, Hepatic, Jecor- (uncommon)

Pancreas - From Greek pankreas, "sweetbread", from pan-, “all”, and -kreas, “flesh”, presumably from the fleshy, uniform nature of the pancreas. Pertaining to the pancreas - Pancrea-

Kidney - From Middle English kidenere, origin unknown. Possibly from cwið , “womb”, and ey, “egg”, for its shape. Pertaining to the kidney - Nephro-, Ren(o)-

Intestines - From the Latin intestina, “inward, intestine”, from intus, “within, on the inside”. [Old English for the organ was hropp, “rope”] Pertaining to the intestines - [Small intestine] Enter(o)-, Duoden-, Jejeun(o)- [Large intestine/Colon] Col(o)-, Sigmoid-

Spleen - From Greek splen, "the milt, spleen". From PIE *splegh-, “milt” [Note: “Milt” - fish sperm - got its name from the Proto-Germanic name for spleen, but the word once meant “guts” in general] Pertaining to the spleen - Splen(o)-

Gall bladder - Gall from Old English galla, “gall, bile”, from PIE root *ghel- "yellowish green, gold". Bladder origin the same as urinary bladder.  Pertaining to the gall bladder - Cholecysto-, [Bile] Chol(e)-

Bladder - From Old English bledre, “urinary bladder, cystic pimple”, from PIE root *bhle-, "to blow" [same root as "blast"!] Pertaining to the bladder - Vesic(o)-, Cyst(o)-

Learn more about medical and biological etymology on Biomedical Ephemera! [Images from Historical Anatomies on the Web] [Etymologies from Online Etymology Dictionary, who you should love and give money to]

[nclexstudyguide]

WE GOT THIS, YOU GUYS!!! 

Happy studying, ^-^b

[nurse-blog]

Medication SUFFIXES

"Caine" - Local Anesthetics

"Done" - Opioid analgesics

"Mycin" - Antibiotics

"Micin" - Antibiotics

"Oxacin" - Broad Spectrum Anti-biotics

"Vir" - Anti-virals

"Dine" - anti-ulcer agents (H2 Histamine Blockers)

"Lam" - anti-anxiety agents

"Pam" - anti-anxiety agents

"Nuim" - neuromuscular blockers

[jwro]

[nurse-on-duty]

Endocrine Disorders

[nurse-blog]

Erikson’s Stages of Psychosocial Development are super super super important to memorize. (mostly the years and the basic conflict) i’ve had a ton of these questions in KAPLAN so far. 

[studentnurse-rn]

Hello Kidneys!

[nurse-blog]

NOTE: 

Antidote for Coumadin = VITAMIN K thus.. if a patient is on coumadin tell them not to ingest any foods with vitamin k (dark leafy greens) as it will decrease coumadins effectiveness, likewise, if a patient has had too much coumadin and is bleeding, we administer vitamin K to reverse!

Antidote for Heparin is Protamine sulfate, if a patient has had too much heparin and is bleeding this is what we administer.

FOR COUMADIN check PT levels

FOR HEPARIN check PTT & APTT levels

[bklynmed-deactivated20160910]

This is one of the most complex medications to administer in terms of dose management 

[adenosinetriesphosphate]

And let’s not forget that other factors and conditions may affect your patients coagulation times (i.e. Aspirin at home).

Did you know patients with Lupus may have really high PTTs despite never being on a blood thinner? Things to bear in mind.

[dieselotherapy]

Ventricular Tachycardia (V-Tach)

Ventricular Tachycardia is a dysrhythmia that usually originates from a single site within the ventricles at a rate greater than 100 bpm. The QRS complex is wide, bizarre and >0.12 seconds. As the heart rate increases, the ventricles do not have the opportunity to completely empty and refill. Therefore, cardiac output is decreased and adequate amounts of blood are not circulated to vital organs. Once the heart rate exceeds 160 impulses per minute, there is usually no effective pumping action of the heart and the patient presents with PULSELESS V-Tach. This patient requires immediate defibrillation. It is possible to have a pulse with V-Tach, however this will degrade into a life threatening dysrhythmia if left untreated.

  Ventricular Fibrillation (V-Fib)

With V-Fib there are many impulses initiated from many locations within the ventricles. As a result the cardiac output is nonexistent and the patient will not have a pulse. The fibrillation may be fine or course waves. As the amplitude of fibrillation waves decreases so does the chance of successful defibrillation and reorganization of a viable perfusing rhythm.

[thebeachmedic]

Have a request for an infographic? Need something explained? Submit a request!

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Works Cited

"Endocrine and Hematologic Emergencies." Emergency Care and Transportation of the Sick and Injured. Ed. Andrew N. Pollak, MD, FAAOS, Leaugeay Barnes,...

[mixmed]

Very funny useful.

[nurse-blog]

They always have a question like this, about teaching elderly how to properly use a cane. REMEMBER, you want to have the cane on the STRONG SIDE. (opposite the weak side)

NCLEX SAMPLE

 The nurse teaches an elderly client with right-sided weakness how to use a cane. Which of the following behaviors, if demonstrated by the client to the nurse, indicates that the teaching was effective?

1. The man holds the cane with his right hand, moves the cane forward followed by the right leg, and then move the left leg.

2. The man holds the cane with his right hand, moves the cane forward followed by his left leg, and then moves the right leg.

3. The man holds the cane with his left hand, moves the cane forward followed by the right leg, and then moves the left leg.

4. The man holds the cane with his left hand, moves the cane forward followed by his left leg, and then moves the right leg.

Answer: 3 

[nurse-on-duty]

General signs and symptoms

social isolation

catatonic behavior

hallucination

incoherence or marked looseness of association

zero or lack of interest, energy and initiative

obvious failure to attain expected levels of development

peculiar behavior

h...

[nurse-on-duty]

ACID-BASE IMBALANCES

[nurse-on-duty]

COMMON CARDIAC RHYTHMS

1. Normal Sinus Rhythm

Rate: 60-100

Rhythm: regular

P waves: similar; 1:1 with QRS

PR: 0.12-0.20 sec; constant

QRS: equal to or less than 0.1 sec

2. Sinus Bradycardia

Rate: <60

Rhythm: regular

P waves: similar; 1:1 with QRS

PR: 0.12-0.20 sec; constant

QRS: equal to or less than 0.1 sec

3. Sinus Tachycardia

Rate: 101-180

Rhythm: regular

P waves: similar; 1:1 with QRS; at very fast rates, P wave looks like T wave

PR: 0.12-0.20 sec; constant

QRS: equal to or less than 0.1 sec

4. Sinus Arrhythmia

Rate: 60-100

Rhythm: irregular; often associated with breathing

P waves: similar; 1:1 with QRS

PR: 0.12-0.20 sec; constant

QRS: equal to or less than 0.1 sec

5. Premature Atrial Contraction

Rate: variable

Rhythm: regular with premature beats

P waves: premature; 1:1 with QRS

PR: dependent on prematurity of the beat

QRS: usually <0.1 sec, but may be wide

6. Supraventricular Tachycardia

Rate: 150-250

Rhythm: regular

P waves: usually obscure but 1:1 with QRS

PR: 0.12-0.20 sec when present

QRS: usually <0.1 sec

7. Atrial Tachycardia

Rate: 150-250

Rhythm: regular

P waves: P waves appear different; may be difficult to distinguish P waves from T waves

PR: may be shorter or longer than normal; ma be hard to measure

QRS: usually equal to or less than 0.1 sec

8. Atrial Flutter

Rate: atrial 250-450; ventricular rate variable

Rhythm: atrial regular; ventricular may be regular or irregular

P waves: no P waves. Flutter (sawtooth shaped) waves observed

PR: not measurable

QRS: usually <0.1 sec

9. Atrial Fibrillation

Rate: atrial 400-600; ventricular variable

Rhythm: ventricular irregular

P waves: no P wave; fibrillatory waves may be present; erratic, wavy baseline

PR: not measurable

QRS: usually <0.1 sec

10. Premature Ventricular Contraction

Rate: 60-100

Rhythm: regular with PVCs

P waves: absent; may appear after QRS complex

PR: none

QRS: >0.12 sec; wide and bizzare

11. Ventricular Tachycardia

Rate: 150-300, typically 200-250

Rhythm: may be regular or irregular

P waves: none

PR: none

QRS: >0.12 sec

12. Asystole

Rate: none

Rhythm: none

P waves: none (“P-wave” asystole)

PR: none

QRS: absent

13. Ventricular Fibrillation

Rate: cannot be determine - no discernible waves or complexes to measure

Rhythm: rapid and chaotic - no pattern

P waves: none

PR: none

QRS: not discernible

14. First-Degree AV Block

Rate: usually normal 60-100

Rhythm: regular

P waves: similar, 1:1 with QRS

PR: prolonged (>0.20 sec) but constant

QRS: usually equal to or less than 0.10 sec

15. Second-Degree AV Block, Type I

Rate: atrial>ventricular

Rhythm: atrial regular; ventricular irregular

P waves: similar, more P waves than QRS

PR: lengthens with each cycle until a P wave appears without a QRS

QRS: usually equal to or less than 0.10 sec; QRS cycle is periodically dropped

16. Second-Degree AV Block, Type II

Rate: atrial > ventricular

Rhythm: atrial regular; ventricular rhythm irregular

P waves: similar, more P waves than QRS

PR: may be normal or prolonged; remains constant

QRS: usually equal to or greater than 0.10 sec; QRS cycle may be absent after P waves

17. Third-Degree AV Block

Rate: atrial > ventricular; usually slow ventricular rate between 30-60

Rhythm: atrial and ventricular; no relationship between the 2

P waves: similar; more P waves than QRS

PR: non; atria and ventricles beat independently of each other

QRS: may be narrow or wide depending on level of the block