EHPLE Nursing cheat sheet

Four ethical principles: autonomy (respect patient choice), beneficence (act for the patient's good), nonmaleficence (do no harm), justice (fair allocation of care).

Informed consent requires capacity, voluntariness, disclosure of risks/benefits/alternatives, and comprehension; the physician obtains consent, the nurse witnesses and clarifies, and the nurse may sign for an emergency when no surrogate exists.

A competent adult may refuse any treatment, including life-sustaining therapy; an informed refusal is documented and does not require a physician's agreement.

Advance directives: a living will states treatment preferences; a durable power of attorney for health care names a surrogate decision-maker; the Patient Self-Determination Act requires hospitals to inform patients of these rights at admission.

Confidentiality is breached only by legal mandate (reportable communicable disease, suspected abuse, gunshot wounds, court order) or with patient authorization; HIPAA permits disclosure for treatment, payment, and operations.

Nurse Practice Acts are state statutes defining scope of practice, licensure, and delegation; the ANA Code of Ethics and specialty standards are non-statutory guides.

Five rights of delegation: right task, right circumstance, right person, right direction/communication, right supervision/evaluation; the RN retains accountability and cannot delegate assessment, care planning, or evaluation.

Torts: negligence requires duty, breach, causation, and damages; malpractice is professional negligence; intentional torts include assault (threat), battery (unwanted touching), and false imprisonment (unjustified restraint).

Good Samaritan laws protect off-duty nurses who render emergency care within their training, without gross negligence or expectation of payment.

Vital sign norms (adult): oral temperature 36.5-37.5 C (97.7-99.5 F); pulse 60-100/min; respirations 12-20/min; blood pressure <120/80 mmHg; SpO2 95-100% on room air.

Orthostatic hypotension: drop of >=20 mmHg systolic or >=10 mmHg diastolic within 3 minutes of standing; measure lying, sitting, and standing.

Normal adult urine output is 30 mL/hr or 0.5 mL/kg/hr; output <400 mL/day is oliguria, <100 mL/day is anuria.

Pressure injury staging: stage 1 intact skin with nonblanchable erythema; stage 2 partial-thickness loss with dermis exposed; stage 3 full-thickness loss with subcutaneous fat visible; stage 4 full-thickness loss with fascia, muscle, bone, or tendon exposed; unstageable is obscured by slough or eschar.

Reposition an immobile patient at least every 2 hours; use the Braden Scale (six subscales, 6-23) to quantify pressure injury risk.

Surgical asepsis applies to sterile fields, urinary catheter insertion, and central line care; sterile items touching nonsterile surfaces are contaminated, and the edges of a sterile wrapper are nonsterile.

Isolation precautions: standard precautions for all patients; contact for MRSA, VRE, C. difficile, and scabies; droplet for influenza, pertussis, and meningococcal meningitis; airborne for tuberculosis, measles, and varicella (N95 respirator, negative-pressure room).

The nursing process sequence is assessment, diagnosis, planning, implementation, evaluation (ADPIE); reassessment and evaluation loop back to assessment.

Maslow-based prioritization places airway, breathing, and circulation first, then safety, then love/belonging, esteem, and self-actualization; physiologic needs outrank psychosocial needs.

Acute coronary syndrome: MONA is outdated; give aspirin 162-325 mg chewed, nitroglycerin (avoid if systolic BP <90 mmHg or with phosphodiesterase-5 inhibitor use), oxygen only if SpO2 <90%, and morphine for refractory pain.

Heart failure: left-sided failure causes dyspnea, orthopnea, crackles, and frothy sputum; right-sided failure causes jugular venous distention, hepatomegaly, and dependent edema; treat acute pulmonary edema with high Fowler position, oxygen, diuretics, and vasodilators.

Digoxin toxicity: therapeutic level 0.5-2.0 ng/mL; signs include nausea, visual halos or yellow-green vision, and bradycardia; hypokalemia potentiates toxicity; hold the dose if apical pulse <60/min in adults.

COPD: oxygen target SpO2 88-92% to avoid hypercarbia; pursed-lip breathing and tripod position reduce air trapping; smoking cessation is the only intervention that slows decline.

DKA versus HHS: DKA shows glucose >250 mg/dL, pH <7.30, bicarbonate <18 mEq/L, ketones, and Kussmaul respirations; HHS shows glucose >600 mg/dL, minimal ketones, and profound dehydration; both need isotonic fluid first, then insulin, with potassium replacement when K+ <5.5 mEq/L.

Hypoglycemia is glucose <70 mg/dL; give 15 g fast-acting carbohydrate if conscious and recheck in 15 minutes; give glucagon 1 mg IM or D50 if unconscious.

Acute kidney injury: prerenal from hypoperfusion, intrarenal from ATN or nephrotoxins, postrenal from obstruction; hyperkalemia and fluid overload are the immediate threats; normal BUN:creatinine ratio is 10-20:1.

Stroke: tPA window is up to 4.5 hours from last known well; exclude hemorrhage by CT before giving it; keep BP <185/110 mmHg before thrombolysis; use the NIHSS to grade severity.

Burns: use the Rule of Nines (head 9%, each arm 9%, each leg 18%, anterior trunk 18%, posterior trunk 18%, perineum 1%); calculate fluid with the Parkland formula 4 mL x kg x %TBSA over 24 hours, half in the first 8 hours from injury time.

Postoperative complications: atelectasis is the most common early complication; hypovolemic shock shows tachycardia, hypotension, and decreased urine output; malignant hyperthermia presents with rising temperature, muscle rigidity, and hypercarbia and is treated with dantrolene.

Naegele's rule: estimated due date = first day of last menstrual period + 7 days - 3 months (or + 9 months).

Fetal heart rate baseline is 110-160/min; accelerations are reassuring; early decelerations mirror head compression; variable decelerations reflect cord compression (reposition, give oxygen); late decelerations reflect uteroplacental insufficiency (turn to side, stop oxytocin, give oxygen, notify provider).

Preeclampsia is BP >=140/90 mmHg after 20 weeks with proteinuria or organ dysfunction; severe features include BP >=160/110, platelets <100,000, transaminases elevated, headache, and visual changes; magnesium sulfate prevents seizures, with therapeutic level 4-7 mEq/L and calcium gluconate as antidote.

Stages of labor: first stage from onset to full dilation (latent 0-6 cm, active 6-10 cm), second stage from full dilation to birth, third stage from birth to placenta delivery, fourth stage the first 1-2 hours postpartum.

Postpartum hemorrhage is blood loss >1000 mL after cesarean or >500 mL after vaginal birth; uterine atony is the most common cause; massage the fundus and give oxytocin.

Lochia progression: rubra (dark red, days 1-3), serosa (pink-brown, days 4-10), alba (white-yellow, days 10-14+); saturating a pad in 1 hour is abnormal.

APGAR scores heart rate, respiratory effort, muscle tone, reflex irritability, and color at 1 and 5 minutes; each 0-2, total 0-10; 7-10 is normal.

Newborn norms: weight 2500-4000 g, respirations 30-60/min, heart rate 110-160/min, temperature 36.5-37.5 C axillary; physiologic jaundice appears after 24 hours, pathologic jaundice within 24 hours.

Breastfeeding: colostrum for the first 2-3 days, then transitional milk; feed 8-12 times per day; signs of adequate intake include 6+ wet diapers daily by day 5 and weight regain by 2 weeks.

Weight doubles by 5-6 months and triples by 12 months; birth weight is regained by 2 weeks; height increases about 2.5 cm per month in the first 6 months.

Infant milestones: social smile at 6 weeks, head control at 4 months, rolling at 5-6 months, sitting unsupported at 8 months, pincer grasp at 9-10 months, walking at 12-15 months.

Vital sign ranges: infant pulse 100-160/min, respirations 30-60/min; toddler pulse 90-150/min, respirations 24-40/min; school-age pulse 70-110/min, respirations 18-30/min.

Pediatric medication dosing uses weight-based mg/kg; safe dose ranges must be verified against published references before administration; Clark's rule and Young's rule are historical approximations.

Dehydration: mild <5% weight loss, moderate 5-10%, severe >10%; use oral rehydration solution for mild-moderate; signs of severe dehydration include sunken eyes, no tears, capillary refill >3 seconds, and lethargy.

Kawasaki disease: fever >=5 days plus conjunctivitis, oral mucositis, rash, cervical lymphadenopathy, and extremity changes; risk of coronary aneurysm; treat with IVIG and high-dose aspirin.

Croup (laryngotracheobronchitis) causes a barking cough and inspiratory stridor; treat with dexamethasone and nebulized epinephrine; epiglottitis causes drooling, tripod posture, and muffled voice and requires no throat inspection.

Intussusception: colicky pain with drawing up of legs, currant-jelly stool, and sausage-shaped mass; air enema is diagnostic and therapeutic.

Congenital heart disease: acyanotic lesions shunt left to right (VSD, ASD, PDA) and cause heart failure; cyanotic lesions shunt right to left (Tetralogy of Fallot, transposition); hypercyanotic spells are treated with knee-chest position, oxygen, and morphine.

Maintain the pediatric chain of survival: prevention, early CPR, rapid activation of emergency response, and advanced care; compression-to-ventilation ratio for two rescuers is 15:2 for children and infants.

Therapeutic communication uses open-ended questions, reflection, restating, and silence; avoid false reassurance, giving advice, why questions, and changing the subject.

Defense mechanisms: denial, projection, displacement, rationalization, regression, repression, sublimation; denial is common in early grief and is not confronted aggressively.

Major depressive disorder: two or more weeks of depressed mood or anhedonia plus five of nine criteria; highest priority nursing assessment is suicide risk.

Serotonin syndrome: clonus, hyperreflexia, agitation, diaphoresis, and hyperthermia after serotonergic drugs; stop the offending agent and give supportive care; cyproheptadine is an antidote.

Neuroleptic malignant syndrome: muscle rigidity, fever, autonomic instability, and elevated creatine kinase after antipsychotics; stop the drug and give dantrolene or bromocriptine.

Lithium therapeutic range is 0.6-1.2 mEq/L; signs of toxicity include tremor, vomiting, diarrhea, ataxia, and confusion; maintain sodium and fluid intake and monitor levels.

Alcohol withdrawal: monitor with the CIWA-Ar; symptoms peak at 24-72 hours; treat with benzodiazepines and thiamine before glucose to prevent Wernicke encephalopathy.

Anorexia nervosa: significantly low body weight, intense fear of weight gain, and body image disturbance; refeeding syndrome risk requires gradual caloric increase and electrolyte monitoring, especially phosphate.

Seclusion and restraint require a time-limited provider order, continuous monitoring, and documentation; they are used only when less restrictive measures fail and the patient is an imminent danger.

Levels of prevention: primary (immunization, seat belts, health education), secondary (screening, Pap smear, mammography, TB skin test), tertiary (rehabilitation, support groups, chronic disease management).

Incidence is new cases over a period divided by the population at risk; prevalence is all existing cases at a point in time; prevalence = incidence x duration for stable disease.

Attack rate = (new cases among exposed / total exposed) x 100; used in outbreak investigation.

Herd immunity threshold depends on R0: for measles R0 12-18 requires about 92-95% vaccination coverage; for polio about 80-85%.

Reportable diseases typically include tuberculosis, hepatitis A/B/C, measles, salmonellosis, gonorrhea, syphilis, and HIV; reporting is mandated by state law.

Epidemiologic triad is host, agent, and environment; the chain of infection is infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, susceptible host.

Community assessment models include the windshield survey, key informant interviews, and the community-as-partner model; a needs assessment precedes program planning.

Screening test properties: sensitivity detects true positives, specificity detects true negatives, positive predictive value depends on prevalence.

Case management coordinates care for high-risk populations; outreach and home visits improve access for underserved groups.

Six rights: right patient, right drug, right dose, right route, right time, right documentation; verify with two identifiers.

High-alert medications include insulin, heparin, opioids, and potassium chloride; independent double-check is required before administration.

Heparin monitoring uses aPTT (therapeutic 1.5-2.5 times control) or anti-Xa; antidote is protamine sulfate; low-molecular-weight heparin is monitored less often and reversed partially with protamine.

Warfarin inhibits vitamin K-dependent clotting factors; monitor INR (target 2-3 for most indications); antidote is vitamin K (phytonadione) plus fresh frozen plasma for major bleeding.

Narrow therapeutic index drugs to monitor: digoxin, lithium, phenytoin, theophylline, warfarin, and aminoglycosides (gentamicin, vancomycin trough).

First-pass metabolism reduces oral bioavailability of drugs such as nitroglycerin and morphine; sublingual and IV routes bypass it.

Antibiotic classes and mechanisms: penicillins and cephalosporins inhibit cell wall synthesis; aminoglycosides inhibit 30S ribosome; macrolides inhibit 50S; fluoroquinolones inhibit DNA gyrase.

Insulin onset: rapid-acting lispro/aspart 15 min, short-acting regular 30 min, intermediate NPH 1-2 hours, long-acting glargine 1-2 hours with no peak.

Opioid adverse effects: respiratory depression, constipation, sedation, and hypotension; naloxone reverses overdose; assess respiratory rate before giving.

Cytochrome P450 interactions: grapefruit juice inhibits CYP3A4; rifampin induces CYP enzymes and lowers levels of many drugs, including oral contraceptives.