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Positioning Patients for Medical
Procedures and Conditions
NCLEX Tips
General Tips
Do not read into the question - never assume anything that has not been specifically mentioned in the question and do not add extra meaning or history to the question. NCLEX land is set at Utopia General Hospital - you have all the time, all the resources, and all the staff you need. Least invasive to most invasive, least restrictive to most restrictive (restraints are rarely a good choice). Avoid using absolutes - always, never, must, etc. Assess the client first before implementing a treatment or action - if there's a choice that pertains to assessment of the patient, it is usually the answer. Assess unless in distress. Priority goes to assessments and answers that deal with the patient (patient-focused) directly and not with machines/monitors/equipment (unless the question is specifically asking about them). If it is the FIRST time doing something for or with the patient (such as vital signs upon admission to the floor/unit, or when a transfer is involved), the NURSE must complete the assessment, including vital signs. If the patient is an adult, answers with family options can be ruled out (unless the patient is not competent to make their own decisions). In emergency situations (mass casualty), patients with a greater chance to live are treated first. If you are asked about the FIRST action you would take in a prioritization/discrimination question, think: "If I can only do one action, and then I must go home, what will the outcome be?" Therapeutic communication - reflect feelings and provide correct information. Do not ask "why" questions (or yes/no) and do not say "I understand". An answer that delays care or treatment is usually wrong (e.g., reassess in 15 minutes, monitor the patient for a continuation of symptoms). When determining interventions to enhance a client's wellness, consider options that promote healthy nutrition, regular exercise, proper weight maintenance, proper rest, and avoidance of harmful chemicals (nicotine) and risk-taking behaviors (not wearing a seat belt). If two of the answer choices are the exact opposite, one is probably the answer (e.g., bradycardia, tachycardia). If two or three answers are similar, none are correct (be careful - sometimes answers may seem similar but in fact are saying something different).
Always look for the UMBRELLA option - one that is a broad universal statement and usually contains the concepts of the other options with it
- often the correct answer. If you have never heard of an answer, do not eliminate it - work around it. If you can safely eliminate all other answers, that is your answer. If you are down to two answers and you know one answer is right, go with what you know. Prioritize actual problems over potential problems. Do not leave the patient - think safety. Do not "do nothing" - you always have to do something. If the question is about endorsement, always report anything new or different to the next shift. Only select "document" if the assessment is normal. Put patients with the same or similar diagnoses in the same room - clean vs. dirty patients. Never increase a patient's fluids to "catch up". Answer SATA questions as true or false for each answer option. Rephrase the question in your own words - this ensures you understand what the question is asking. If you cannot rephrase the question, you do not know what the topic is. If you cannot determine the topic of the question, read all answer choices to help you understand the problem (look for patterns). Try not to determine the answer before reading the answer choices - NCLEX uses traps and answers that scream "pick me" but are wrong. More often than not, pain will not be your answer - pain is considered psychosocial. The exception to this rule are signs and symptoms of compartment syndrome. Try to focus on the here and now as much as possible. With positioning questions, you are trying to prevent or promote something - evaluate the outcome of each option. When the question asks what is ESSENTIAL, think SAFETY. If you do not know what a word means, try to break it down using medical terminology. For example, Rhabdomyosarcoma - muscle (myo), tumor (sarcoma) → tumor of the muscle tissue. The same idea applies to medications - use suffixes and prefixes to recognize classifications. Make an educated guess - if you can't make the best answer for a question after carefully reading it, choose the answer with the most information. When in doubt, SAFETY.
Prioritization Techniques
Prioritize systemic vs. local (life before limb). Prioritize acute before chronic. Prioritize actual before potential future problems. Prioritize according to Maslow's - physiological needs before psychosocial (acute safety can take priority - ATI). Recognize and respond to trends vs. transient findings (recognizing a gradual deterioration). Recognize signs of emergencies and complications vs. "expected client findings".
Strep, untreated can cause acute glomerulonephritis (periorbital edema - indicates poststreptococcal glomerulonephritis).
Order of PPE Application and Removal
Application: 1. Gown 2. Mask 3. Goggles/face shield 4. Gloves
Removal: 1. Gloves 2. Goggles/face shield 3. Gown 4. Mask
Additional Information
The most effective method of preventing the spread of infection is to make supplies for hand hygiene readily available for staff to use, as the hands of healthcare workers are the most common means of transmission of infection from one client to another. For avian influenza, the nurse's initial action should be to start oxygen therapy due to the potentially life-threatening respiratory manifestations. According to the CDC, catheter-associated UTIs are the most common healthcare-acquired infection in the US, and primary CDC recommendations include avoiding the use of indwelling catheters and removing catheters as soon as possible. Individuals who have contact with infants should be immunized against pertussis in order to avoid infection and prevent transmission to the infant. The ventilator bundle developed by the Institute for Healthcare Improvement includes recommendations for continuous elevation of the head of the bed (30 to 45 degrees), daily assessment for extubation readiness, and daily oral care with chlorhexidine solution.
Chlorhexidine and Central-Line Associated
Bloodstream Infections (CLABSIs)
Chlorhexidine is more effective than other options at reducing the risk for central-line associated bloodstream infections (CLABSIs).
Potassium Administration
No pee, no K (do not give potassium without adequate urine output).
Intravenous (IV) Push Administration
IV push should be given over 2 minutes.
Unit Conversions
1 oz = 30 mL 1 cup = 8 oz
1 kg = 2.2 lbs 1 lb = 16 oz 1 gr (grain) = 60 mg
Converting Temperature
To convert Celsius (C) to Fahrenheit (F): C + 40, multiply by 9/5, and subtract 40 To convert Fahrenheit (F) to Celsius (C): F + 40, multiply by 5/9, and subtract 40
Positioning Patients
Asthma
Patients should be placed in an orthopneic position, sitting up and bent forward with arms supported on a table or chair arms.
Air Embolism
Patients should be turned to the left side and the head of the bed lowered.
Pulmonary Embolism
The head of the bed should be elevated.
Non-Reassuring Fetal Heart Rate in Labor
The mother should be turned to the left side (and given oxygen, Pitocin stopped, and IV fluids increased).
Tube Feeding with Decreased Level of Consciousness
The head of the bed should be elevated, and the patient positioned on the right side to promote gastric emptying.
Postural Drainage
The lung segment to be drained should be in the uppermost position to allow gravity to work.
Epidural/Lumbar Puncture
The patient should be in a side-lying ("C" curved spine) or lateral recumbent/fetal position.
Post Total Hip Replacement
The patient should not sleep on the affected/operative side, flex the hip more than 45-60 degrees, or elevate the head of the bed more than 45 degrees. The hip should be maintained in abduction with a pillow between the thighs, and no adduction or internal rotation should occur.
Prolapsed Cord
The patient should be placed in a knee-chest or Trendelenburg position to prevent pressure on the cord.
Vena Cava Syndrome in Pregnant Women
The patient should be positioned on the left side with knees flexed to relieve pressure on the vena cava from the fetus. The mother may present with hypotension.
Infant with Cleft Lip
The patient should be positioned on the back or in an infant seat to prevent trauma to the suture line. While feeding, the infant should be held in an upright position.
Infant with Cleft Palate
The patient should be positioned prone.
Pancreatitis
Patients should lie in a fetal position and maintain NPO (nothing by mouth) status. A PICC line may be inserted for total parenteral nutrition (TPN) and lipids.
To Prevent Dumping Syndrome
Patients should eat in a reclining position, lie down after meals for 20- minutes, and restrict fluids during meals. A low-carbohydrate, low-fiber, high-fat, and high-protein diet should be followed to decrease gastric motility.
Enema Administration
The patient should be positioned in a left-side lying (Sim's) position with knees flexed.
Above Knee Amputation
The residual limb should be elevated on a pillow for the first 24 hours. The patient should be positioned prone daily to provide for hip extension. The leg
should not be kept elevated beyond 24 hours, as this can lead to hip flexion and contractures.
Below Knee Amputation
The foot of the bed should be elevated for the first 24 hours. The patient should be positioned prone daily to provide for hip extension. The leg should not be kept elevated beyond 24 hours, as this can lead to hip flexion and contractures.
Detached Retina
The area of detachment should be in the dependent position, with the head in a downward direction and the patient lying on the unaffected side.
After Supratentorial Surgery
The head of the bed should be elevated 30-45 degrees.
After Intratentorial Surgery
The patient should be positioned flat and lateral on either side.
During Internal Radiation
The patient should be on bed rest while the implant is in place.
Autonomic Dysreflexia/Hyperreflexia
The patient should be placed in a sitting position (high Fowler's) to decrease venous return. The tubing of the Foley catheter should be checked for kinks.
Spinal Cord Injury
The patient should be immobilized on a spine board, with the head in a neutral position, immobilized with a padded C-collar, and the head maintained in traction and alignment manually. The patient should be log- rolled and not allowed to twist or bend.
Shock
The patient should be on bed rest with the extremities elevated 20 degrees, knees straight, and the head slightly elevated (modified Trendelenburg).
Head Injury
The head of the bed should be elevated 30 degrees to decrease intracranial pressure (ICP).
Paracentesis
The patient should be in a semi-Fowler's or upright position on the edge of the bed. The patient should void prior to the procedure to prevent bladder puncture. Vital signs, temperature, and signs of hypovolemia should be monitored post-procedure.
Pneumonia
The patient should be laid on the affected side to splint and reduce pain. Positioning the sick lung upward can help reduce congestion.
Post-Appendectomy
The patient should be positioned on the right side with the legs flexed.
Gastroesophageal Reflux Disease (GERD)
The patient should be laid on the left side with the head of the bed elevated 30 degrees to increase sphincter pressure.
Postural Drainage
The patient's head should be in a dependent position.
Post-Radical Mastectomy
The patient should be in a semi-Fowler's position with the affected arm elevated. This facilitates the removal of fluid through gravity and enhances circulation.
Additional Information
Prior to a liver biopsy, it is important to check the patient's prothrombin time (PT) due to the vascular nature of the organ. Vitamin K should be administered, and the patient should be NPO (nothing by mouth) after midnight before a liver biopsy. The patient will be asked to hold their breath for 5-10 seconds during the procedure. Morphine is contraindicated in pancreatitis, as it can cause spasm of the Sphincter of Oddi. Demerol is the pain medication of choice. After pain relief in pancreatitis, it is important for the patient to cough and deep breathe, as fluid is pushing up on the diaphragm. In chronic pancreatitis, pancreatic enzymes are given with meals.
Diabetes Mellitus
Types of Diabetes Mellitus
Type I (insulin-dependent): An immune disorder where the body attacks insulin-producing beta cells, resulting in ketosis. Type II (insulin-resistant): The beta cells do not produce enough insulin, or the body becomes resistant to insulin.
NCLEX Points for Diabetes Mellitus
Assessment
The 3 P's: Polyuria (excessive urination), polydipsia (extreme thirst), polyphagia (excessive hunger) Elevated blood sugar Blurred vision Elevated HbA1C Poor wound healing Neuropathy Inadequate circulation End-organ damage due to vessel damage (coronary artery disease, hypertension, cerebrovascular disease, retinopathy)
Therapeutic Management
Insulin is required for Type I and when diet and exercise do not control blood sugar in Type II. Assess for and teach the patient regarding peak action time for various insulins. Only administer short-acting insulins intravenously. Patients should monitor blood sugar before, during, and after exercise, and use protective footwear to prevent injury. Infections and wounds should receive meticulous care. Feet should be kept dry, and properly fitted shoes and cotton socks should be worn. During sick days, patients should continue to check blood sugars and not withhold insulin. Monitor for ketones in the urine. The 15 Rule: If blood sugar is low, administer 15g of carbohydrates and recheck in 15 minutes.
Complications
Lipoatrophy (loss of subcutaneous fat at injection site) and lipohypertrophy (fatty mass at injection site) Dawn phenomenon (reduced insulin sensitivity between 5-8 AM) and Somogyi phenomenon (nighttime hypoglycemia resulting in rebound hyperglycemia)
DKA is rare in type 2 diabetes because there is enough insulin to prevent the breakdown of fats. Serum acetone and serum ketones increase in DKA. As the acidosis and dehydration are treated, the potassium level can drop rapidly, requiring potassium replacement. Fluids, such as normal saline (NS) or lactated Ringer's (LR), are the most important intervention for DKA and HHNS. The second voided urine is the most accurate when testing for ketones and glucose. Bringing the glucose down too quickly can result in increased intracranial pressure (ICP) due to water being pulled into the cerebrospinal fluid (CSF). Urine ketone testing should be done whenever the patient's blood glucose is greater than 240 mg/dL.
Hyperosmolar Hyperglycemic Nonketotic Syndrome
(HHNS)
Potassium is low due to diuresis. Fluids are the most important intervention. There is no acidosis and no ketosis. Weight loss is a symptom. HHNS often occurs in older adults with type 2 diabetes. Risk factors include diuretics and inadequate fluid intake (dehydration).
Glycemic Control and Surgical Considerations
HbA1c assesses how well blood sugar has been managed over a 3- month period. A range of 4-6% is good, and 8% or greater indicates poor control. The ideal for a diabetic is 7%. Insulin is usually held prior to surgery, and blood glucose is monitored. To remember blood sugar levels: Hot and dry, sugar high (hyperglycemia) Cold and clammy, need some candy (hypoglycemia)
Laparoscopic Procedures
In laparoscopy, CO2 is used to enhance visual, and general anesthesia and a Foley catheter are used. Post-operatively, early ambulation is important to mobilize the CO2.
Myasthenia Gravis
Myasthenia Gravis is a condition characterized by a decrease in receptor sites for acetylcholine, leading to fatigue and weakness in the eye, mastication/chewing, and pharyngeal muscles. Sometimes, the first sign is that the patient can't brush their hair. The diagnosis is made via the Tensilon test, which shows improvement in muscle weakness for a short period.
Patients should avoid alcohol, crowded places, and try to reduce stress. They should also avoid heat (sauna, hot tub, sunbathing) and spread activities throughout the day. Thickening liquids may also help. Myasthenic crisis often follows some type of infection and can lead to inadequate respiratory function. Cholinergic crisis is caused by excessive medication, and stopping the medication will make it worse.
Head Injury and Medication
Mannitol (an osmotic diuretic) crystallizes at room temperature, so a filter needle must always be used.
Endocrine System
The table below summarizes the key hormones, their associated glands, and their functions:
| Hormone | Gland | | --- | --- | | Growth Hormone (GH) | Anterior Pituitary | | Antidiuretic Hormone (ADH) | Posterior Pituitary | | Thyroid Hormones (T3, T4) | Thyroid | | Parathyroid Hormone (PTH) | Parathyroid | | Glucocorticoids (Cortisol) | Adrenal Gland | | Insulin | Pancreas |
The parathyroid gland relies on the presence of Vitamin D to work. Palpating the thyroid gently can cause a thyroid storm in a patient with hyperthyroidism. After the removal of the pituitary gland, watch for hypocortisolism and temporary Diabetes Insipidus.
Myxedema/Hypothyroidism
Myxedema/Hypothyroidism is a hyposecretion of thyroid hormone, resulting in a decreased metabolic rate and slowed physical and mental function. Myxedema coma is a life-threatening state of decreased thyroid production, often caused by acute illness, rapid cessation of medication, or hypothermia. NCLEX points for assessment include a hypo-metabolic state, bradycardia, anemia, hypotension, constipation, lethargy, fatigue, weakness, muscle aches, paresthesias, goiter, dry skin and hair, loss of body hair, cold intolerance, anorexia, weight gain, and edema. Therapeutic management includes cardiac monitoring, maintaining an open airway, monitoring medication therapy, administering levothyroxine (Synthroid), assessing thyroid hormone levels, providing IV fluids, and monitoring and administering glucose as needed.
Phosphorus Imbalances
Low phosphorous can lead to generalized muscle weakness and acute muscle breakdown (rhabdomyolysis), as phosphate is necessary for energy production in the form of ATP.
Diabetes Insipidus (DI)
Diabetes Insipidus is a hyposecretion or failure to respond to ADH from the posterior pituitary, leading to excessive water loss. Assessment includes excessive urine output, dilute urine (USG <1.006), hypotension, tachycardia, polydipsia, hypernatremia, and neurological changes. Therapeutic management includes water replacement (D5W if IV), hormone replacement (desmopressin, vasopressin), monitoring urine output and specific gravity, and daily weight monitoring.
Syndrome of Inappropriate Antidiuretic Hormone (SIADH)
SIADH is an excessive secretion of ADH, leading to hyponatremia and water intoxication. Causes include trauma, tumors, infection, and medications. Assessment includes fluid volume excess, altered level of consciousness, seizures, coma, urine specific gravity greater than 1.032, and decreased BUN, hematocrit, and sodium. Therapeutic management includes cardiac monitoring, frequent neurological exams, fluid restriction, sodium supplementation, daily weight monitoring, and medications like hypertonic saline, diuretics, and electrolyte replacement.
Adrenal Gland Disorders
Addison's Disease
Addison's Disease is a hyposecretion of adrenal cortex hormones, leading to hyponatremia, hyperkalemia, hypoglycemia, decreased vascular volume, and hypotension. Assessment includes hyponatremia, hyperkalemia, hypoglycemia, decreased blood volume, hypotension, weight loss, hyperpigmentation, and decreased resistance to stress. Therapeutic management includes monitoring vital signs, electrolytes, and glucose, treating low blood sugar, administering replacement adrenal hormones, and managing stress, as further stress can lead to Addisonian Crisis. Addisonian Crisis is a severe exacerbation of Addison's Disease, requiring close monitoring of electrolytes and cardiovascular status, administration of adrenal hormones, and management of symptoms like nausea/vomiting, confusion, abdominal pain, weakness, hypoglycemia, and dehydration.
Cushing's Disease
Cushing's Disease is a hypersecretion of glucocorticoids, leading to elevated cortisol levels. Assessment includes hypernatremia, hypokalemia, hyperglycemia, increased blood volume, hypertension, proneness to infection, moon face, buffalo hump, muscle wasting, edema, and increased bruising. Therapeutic management includes monitoring electrolytes and cardiovascular status, preventing fluid overload, providing skin care and wound care, ensuring client safety, and considering adrenalectomy (surgical removal of the adrenal gland).
Pheochromocytoma
Pheochromocytoma is a vascular tumor of the adrenal medulla, leading to hypersecretion of epinephrine and norepinephrine. Symptoms include persistent hypertension, increased heart rate, hyperglycemia, diaphoresis, tremor, and pounding headache. Management includes avoiding stress and frequent bathing, taking rest breaks, avoiding stimulating foods and high-tyramine foods, and avoiding palpation of the abdomen, as it can cause a sudden release of catecholamines and severe hypertension. Treatment is surgical removal of the tumor.
Other Conditions
Neuroleptic Malignant Syndrome (NMS)
Neuroleptic Malignant Syndrome is a life-threatening condition characterized by hyperpyrexia, increased muscle tone, diaphoresis, and increased blood pressure, pulse, and respirations.
Pulmonary Embolism
The first signs of a pulmonary embolism are sudden chest pain, followed by dyspnea and tachypnea. Oxygen is usually the first intervention, as the patient may be hyperventilating as a compensatory mechanism. Risk factors include obesity, immobility, pooling of blood in the extremities, and trauma.
Tetralogy of Fallot
Tetralogy of Fallot is a congenital heart defect characterized by a defect in the septal wall, right ventricular hypertrophy, overriding aorta, and pulmonary stenosis. For neonates with Tetralogy of Fallot, a prostaglandin E1 infusion is given. Oxygen and morphine, along with IV fluids for volume expansion, are also provided.
Anorexia Nervosa
One of the goals for a client with anorexia is to achieve a sense of self-worth and self-acceptance that is not based on appearance. The nurse should encourage activities that will promote socialization and increase self-esteem.
Physical Signs and Symptoms of Anorexia
Amenorrhea Constipation Hypotension Cold intolerance Bradycardia Fatigue Muscle weakness Osteoporosis
Autonomic Dysreflexia
Autonomic Dysreflexia is a potentially life-threatening emergency seen in patients with spinal cord injuries, typically at T6 or above. The nurse should:
Elevate the head of the bed to 90 degrees (first action). Assess for bladder distention and bowel impaction, as these can trigger Autonomic Dysreflexia (second action). Administer anti-hypertensive medications, as Autonomic Dysreflexia can cause sudden, acute onset of hypertension, which may lead to stroke, MI, or seizure.
Drug Schedules
Schedule I: No currently accepted medical use, research only (e.g., heroin, LSD, MDMA) Schedule II: High potential for abuse, requires written prescription (e.g., Ritalin, hydromorphone/Dilaudid, meperidine/Demerol, fentanyl) Schedule III: Requires new prescription after 6 months or five refills (e.g., codeine, testosterone, ketamine) Schedule IV: Requires new prescription after 6 months (e.g., benzodiazepines) Schedule V: Dispensed as any other prescription or without prescription (e.g., cough preparations, laxatives)
Medication Considerations
Digoxin
Assess pulse for a full minute and hold if HR is less than 60 Check digoxin levels, potassium, and magnesium levels (low K and Mg can lead to digoxin toxicity)
Signs of toxicity: yellow halo, nausea/vomiting Digoxin is given with loading doses (normally 2- 0.5mg or higher), and the maintenance dose is typically 0.25mg Increases ventricular irritability, can convert a rhythm to V-Fib following cardioversion
Aluminum Hydroxide (Amphojel)
Used for the treatment of GERD and kidney stones Watch for constipation Take after meals
Amiodarone
Treats life-threatening heart rhythm problems Watch for diaphoresis, dyspnea, lethargy Take missed dose any time in the day or skip it entirely, do not take a double dose
Warfarin (Coumadin)
Anticoagulant therapy Watch for signs of bleeding, diarrhea, fever, or rash Stress the importance of complying with prescribed dosage and follow- up appointments Patients should not make sudden dietary changes, as changing the intake of foods high in Vitamin K (green leafy vegetables, some fruits) will impact the effectiveness of the medication
Methylphenidate (Ritalin)
Treatment of ADHD Assess for heart-related side effects and report immediately Child may need drug holiday because the drug can stunt growth Parents should watch for weight loss due to poor appetite
Ethambutol (TB)
Negative effect on eyes (blurred vision, eye pain, red-green color blindness, any loss of vision—more common with high doses) Liver problems may occur
Gemfibrozil
Lowers high cholesterol and triglycerides Monitor liver functions, increased risk of gallstones and rhabdomyolysis
Dextroamphetamine (Dexedrine)
Used for ADHD
