NLN ACE PN-RN cheat sheet

Myocardial infarction: MONA is outdated; current priority is aspirin 325 mg chewed, nitroglycerin if no right-ventricular infarct or PDE-5 inhibitor use, oxygen only if SpO2 < 90%, and reperfusion within 90 minutes of PCI door time.

Heart failure exacerbation: position high-Fowler, give loop diuretic IV, monitor potassium (hypokalemia from diuresis, hyperkalemia from ACE inhibitors/spironolactone), weigh daily; 2-3 lb overnight gain or 5 lb weekly gain signals fluid retention.

COPD: target SpO2 88-92% to avoid oxygen-induced hypercapnia; pursed-lip breathing prolongs expiration; administer bronchodilators before corticosteroids; encourage incentive spirometry and hydration to thin secretions.

Stroke: thrombolytic (alteplase) window is 3-4.5 hours from last known well; contraindicated if BP > 185/110, recent surgery, or anticoagulation; keep head midline, avoid neck flexion, and do not lower BP unless > 220/120.

Increased intracranial pressure: elevate head of bed 30 degrees, keep head midline, avoid hip flexion and Valsalva, maintain PaCO2 35-45; early signs are decreased LOC and pupil changes, late sign is Cushing triad (bradycardia, hypertension, irregular respirations).

Diabetic ketoacidosis: IV isotonic fluids first, then regular insulin IV infusion, add dextrose when glucose reaches ~200-250 mg/dL, and monitor potassium closely because insulin drives potassium intracellularly causing hypokalemia.

Acute pancreatitis: NPO initially, aggressive IV fluids, pain control, monitor for hypocalcemia (positive Trousseau/Chvostek) and hemorrhage (Cullen sign, Grey Turner sign); avoid routine antibiotics unless infected necrosis.

Cirrhosis with ascites: low-sodium diet, daily weights and abdominal girth, paracentesis (remove no more than 5 L without albumin), monitor for hepatic encephalopathy (asterixis, confusion) and variceal bleeding.

Postoperative care: priority is airway, breathing, circulation; prevent atelectasis with incentive spirometry and early ambulation; assess for DVT (calf pain, unilateral swelling) and dehiscence (support abdomen when coughing).

Fetal heart rate baseline is 110-160 bpm; early decelerations mirror contractions (head compression, benign), variable decelerations are abrupt (cord compression, reposition), late decelerations follow contractions (uteroplacental insufficiency, turn to side, stop oxytocin, give oxygen).

Magnesium sulfate for preeclampsia: monitor respiratory rate ≥12, deep tendon reflexes present, urine output ≥30 mL/hr; antidote is calcium gluconate 1 g IV; toxicity signs are loss of reflexes, respiratory depression, oliguria.

Postpartum hemorrhage: most common cause is uterine atony; massage fundus, empty bladder, give oxytocin then methylergonovine (contraindicated in hypertension) or carboprost (contraindicated in asthma).

Lochia progression: rubra (dark red, days 1-3), serosa (pink-brown, days 4-10), alba (white-yellow, days 11+); saturated pad in 1 hour or large clots warrant immediate assessment.

Newborn APGAR at 1 and 5 minutes scores Appearance, Pulse, Grimace, Activity, Respiration (0-2 each, max 10); score ≥7 is generally reassuring; resuscitation begins before the 1-minute score is assigned.

Newborn thermoregulation: cold stress leads to increased oxygen consumption and metabolic acidosis; maintain skin-to-skin, dry immediately, use radiant warmer; normal axillary temperature is 36.5-37.5 degrees C.

Physiologic jaundice appears after 24 hours and peaks at 3-5 days; jaundice within the first 24 hours is always pathologic and requires immediate bilirubin measurement and provider notification.

Stages of labor: first stage latent (0-6 cm) and active (6-10 cm), second stage is full dilation to birth, third is birth to placenta delivery, fourth is the first 1-2 hours postpartum when hemorrhage risk is highest.

Breastfeeding: colostrum in the first days is high in immunoglobulin A; feed on demand 8-12 times per 24 hours; signs of adequate intake are 6+ wet diapers daily by day 5 and audible swallowing.

Pediatric vital signs by age: infant heart rate 100-160, toddler 90-150, preschool 80-140, school-age 70-120; respiratory rates fall with age; blood pressure lower limit for a child is 70 + (2 x age in years).

Weight-based dosing: verify safe dose range per kg against the ordered dose before administration; a child's dose often exceeds the adult dose per kg because of higher metabolic rate and water content.

Dehydration in children: 1 kg weight loss equals 1 L fluid; signs of severe dehydration include sunken fontanel, absent tears, capillary refill > 2 seconds, and lethargy; use oral rehydration solution in small frequent amounts when tolerated.

Kawasaki disease: fever ≥5 days plus conjunctivitis, mucosal changes, rash, cervical lymphadenopathy, and extremity changes; risk is coronary aneurysm, so give IVIG and aspirin and monitor for cardiac complications.

Intussusception: colicky abdominal pain with drawing up of legs, currant-jelly stools, and sausage-shaped mass; air enema is both diagnostic and therapeutic; report immediately if it recurs.

Epiglottitis: drooling, tripod positioning, muffled voice, high fever; do not examine the throat or use a tongue blade because it can trigger airway obstruction; keep the child calm and prepare for intubation.

Croup: barking cough, hoarse voice, inspiratory stridor; treat with nebulized epinephrine for stridor at rest and dexamethasone; humidified air and calm reassurance reduce distress.

Febrile seizures: most occur between 6 months and 5 years, are generalized, and last under 15 minutes; place the child on the side, do not restrain or place anything in the mouth, and treat the fever after the seizure ends.

Failure to thrive and child abuse: document objectively, use a body diagram for injuries, follow mandatory reporting laws; patterned or inconsistent injuries, delay in seeking care, and injury history that does not match development are red flags.

Six rights of medication administration: right client (two identifiers), right drug, right dose, right route, right time, and right documentation; verify allergies before every administration.

Hand hygiene is the single most effective infection control measure; use soap and water for C. difficile and norovirus because alcohol-based sanitizer does not kill spores; scrub for at least 20 seconds.

Normal adult vital signs: temperature 36.5-37.5 degrees C, pulse 60-100 bpm, respirations 12-20/min, blood pressure < 120/80, SpO2 ≥ 95%; report changes outside these ranges promptly.

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

Sterile technique: sterile field is contaminated by contact with unsterile objects, moisture, or reaching over it; keep hands above waist level and never turn away from the field.

Maslow and airway priority: ABCs (airway, breathing, circulation) always precede psychosocial needs; among stable clients, use Maslow's hierarchy, with safety and physiological needs first.

Isolation precautions: contact for MRSA, VRE, C. difficile, and scabies; droplet for influenza, pertussis, and meningitis; airborne for tuberculosis, measles, and varicella, requiring an N95 mask.

Intake and output: 1 mL of urine weighs 1 g; 30 mL equals 1 ounce; record all oral, IV, tube feeding, and irrigant intake and all urine, emesis, drainage, and stool output; report urine output < 30 mL/hr.

Documentation: record objective, factual observations, not opinions; document after care, not before; late entries are marked as such; incident reports are not placed in the medical record.

Digoxin: therapeutic range 0.5-2 ng/mL; hold and notify provider if apical pulse is < 60 in adults or < 90-110 in infants; early toxicity signs are nausea, anorexia, visual halos, and confusion; monitor potassium.

Warfarin: monitor INR, target 2-3 for most indications; antidote is vitamin K; avoid consistent large intake of vitamin K-rich greens; bleeding precautions include soft toothbrush and electric razor.

Heparin: monitor aPTT and platelets; antidote is protamine sulfate; watch for heparin-induced thrombocytopenia; low-molecular-weight heparin requires no routine aPTT monitoring.

Insulin: rapid-acting (lispro, aspart) peaks 1-3 hours, regular peaks 2-4 hours, NPH peaks 4-12 hours, glargine is peakless basal; monitor for hypoglycemia (glucose < 70, sweating, tremor, confusion) and give 15 g fast-acting carbohydrate.

Aminoglycosides (gentamicin, tobramycin): nephrotoxic and ototoxic; monitor peak and trough levels, creatinine, and hearing; trough levels drawn before the next dose.

Vancomycin: monitor trough levels and renal function; infusion reaction (flushing, hypotension, erythema) is reduced by infusing over at least 60 minutes; monitor for ototoxicity and nephrotoxicity.

Opioids: adverse effects are respiratory depression, constipation, and hypotension; antidote is naloxone; assess respiratory rate and sedation level before and after administration; do not crush extended-release forms.

Corticosteroids: do not stop abruptly (adrenal insufficiency); give with food to reduce GI irritation; monitor glucose, weight, and signs of infection; side effects include hyperglycemia, osteoporosis, and immunosuppression.

High-alert medications (insulin, heparin, opioids, chemotherapy, potassium chloride) require independent double-check by a second nurse; concentrated potassium chloride is never given IV push.