NSG210 Exam 3 Topic Guide

The Exam 3 topics, each with the textbook section to read (with printed page numbers), the lecture notes and chapter outline, and a short list of what to know. Med-surg chapters are from Hinkle & Cheever, Brunner & Suddarth’s Medical-Surgical Nursing, 15th ed.; maternity chapters are from Durham & Chapman, 4th ed. The course syllabus uses 16th-edition chapter numbers, which are one higher from Ch. 21 on (see nsg210-textbook-chapter-crosswalk).

Each topic also has a “From the lecture” list with the points from the Week 08-10 lecture notes that the textbook list does not cover: drug-specific details, slide values, and the lessons from the lecture case studies.

When the lecture slides and the textbook give different values, see nsg210-exam-3-lecture-vs-textbook.

Topic Map

Cancer

Oncology

Read: Hinkle Ch. 12. Outline: nsg210-hinkle-ch12-oncologic-management.

What to know:

• Benign vs malignant: a malignant tumor invades and metastasizes. Know staging (TNM) and grading.
• Prevention and screening: risk reduction and the warning signs of cancer.
• Radiation:
  • External beam: skin care with no lotions on the marked field and sun protection.
  • Internal (brachytherapy): time, distance, shielding; a private room; limited visitors; no pregnant visitors or staff.
• Chemotherapy:
  • The nadir is when counts are lowest.
  • Vesicant extravasation: stop the infusion and follow protocol.
  • Handle as hazardous drugs (PPE, disposal).
  • Watch for nausea and vomiting (premedicate) and alopecia.
• Neutropenia: fever is an emergency (cultures, then antibiotics fast). Use hand hygiene, avoid sick contacts, no fresh flowers or raw foods if your facility restricts them, and give no rectal meds or temperatures.
• Thrombocytopenia: bleeding precautions, soft toothbrush, electric razor, no IM injections.
• Mucositis: oral care, a soft diet, and no alcohol-based mouthwash.
• Oncologic emergencies:
  • Tumor lysis syndrome: high potassium, phosphate, and uric acid with low calcium after treatment of bulky tumors. Hydrate and give allopurinol or rasburicase.
  • Superior vena cava syndrome: facial and neck swelling and dyspnea.
  • Spinal cord compression: back pain first, then weakness and bowel or bladder changes.
  • Hypercalcemia.
  • Sepsis and DIC.
  • SIADH.

From the lecture (Week 09, cancer lecture):

• Spread: lymphatic spread is the most common; tumors also spread through the blood and grow their own capillaries (angiogenesis).
• Terms: carcinoma is epithelial tissue; sarcoma is connective tissue, muscle, or bone; leukemia, myeloma, and lymphoma are blood and lymph.
• Grading: well differentiated cells mean a better prognosis; poorly differentiated, a worse one.
• CAUTION warning signs: change in bowel or bladder habits, a sore that does not heal, unusual bleeding or discharge, a thickening or lump, indigestion or trouble swallowing, an obvious change in a wart or mole, a nagging cough or hoarseness.
• Tumor markers: PSA (prostate), CA-125 (ovary), AFP (liver, seminoma), CEA (colon and others), calcitonin (medullary thyroid), immunoglobulins (myeloma).
• Screening: the slides show an older table with colorectal screening from 50; the textbook says 45.
• Radiation: rapidly dividing tissue is most sensitive. Watch for skin reactions, mucositis, GI effects, and radiation pneumonitis. With implants, body fluids need special handling.
• Chemotherapy:
  • Dose is based on body surface area.
  • Nadir is the lowest blood count (textbook: 7-14 days after the dose); check the CBC often.
  • Nausea and vomiting are the most common effect; give antiemetics such as ondansetron.
  • Offer sperm banking before treatment.
• Drug-specific toxicities:

• Cancer pain: oral route while it works, on a schedule around the clock. Morphine and transdermal fentanyl are the most common drugs. Never stop high-dose opioids abruptly.
• Older adults: more chemotherapy toxicity, and they often delay reporting symptoms as “just age.”
• Hospice: for a life expectancy of 6 months or less; focus on quality of life and symptom relief.

Lung Cancer and Chest Tubes

Read: Hinkle Ch. 19. Outline: nsg210-hinkle-ch19-chest-lower-respiratory-disorders.

What to know:

• Lung cancer:
  • Smoking is the main risk factor; also radon and occupational exposures.
  • Small cell grows fast and spreads early (chemo and radiation). Non-small cell is more often surgical.
  • Signs: a new or changed cough, hemoptysis, dyspnea, recurrent pneumonia, weight loss.
• After lung surgery:
  • Airway clearance (cough, deep breathing, incentive spirometry) and pain control so the patient can breathe deeply.
  • Early ambulation.
  • After a pneumonectomy, the patient has no chest tube (or only a clamped one per surgeon) and positioning follows surgeon orders.
• Chest tube systems:
  • The collection chamber measures drainage.
  • The water-seal chamber is the one-way valve. Tidaling (rise with inspiration, fall with expiration in a spontaneously breathing patient) is expected.
  • Continuous bubbling in the water seal means an air leak.
  • In the suction-control chamber, gentle continuous bubbling is expected with wet suction.
• Chest tube safety:
  • Keep the system below the chest, tubing free of dependent loops, and connections taped.
  • Do not clamp routinely or strip the tubing.
  • Report drainage of 150 mL/hr or more (lecture and textbook), or drainage that is bright red, warm, and free flowing, or a sudden change.
• Emergencies:
  • If the tube disconnects, put the end in sterile water.
  • If the tube is pulled out, cover the site with a dressing taped on three sides and notify the provider.

From the lecture (Week 09, lung cancer and chest tubes):

• Types: non-small cell is 85% (adenocarcinoma is the most common and peripheral; squamous cell is central). Small cell has a 5-year survival of 5-10%. Small cell gets combination chemotherapy; non-small cell gets surgery.
• Paraneoplastic syndromes: SIADH (hyponatremia), hypercalcemia with low phosphate (slide 5 says “hyperphosphatemia,” which is an error), Cushing syndrome, clubbing, and Lambert-Eaton weakness.
• Diagnosis: chest X-ray is often the first clue. Collect sputum for cytology first thing in the morning. Bronchoscopy allows biopsy.
• Surgery:
  • Lobectomy is the procedure of choice for a tumor in one lobe, usually with two chest tubes (upper for air, lower for fluid).
  • Wedge resection is the most conservative.
  • After pneumonectomy there is usually no chest tube. Turn the patient only to the back or the operative side, never fully onto the unoperated side.
• After surgery: check chest tube output every hour at first. Postoperative complications that impair gas exchange: pneumothorax, atelectasis, bronchospasm, PE, ARDS.
• Tube placement: the tube for air goes high (2nd intercostal space). The larger tube for blood goes low (4th-5th intercostal space).
• Wet suction: the water height in the suction-control chamber sets the suction, usually 20 cm H2O, not the wall regulator.
• Tidaling stops when: the lung has re-expanded, the tube is blocked (clot, kink), a loop hangs dependent, or suction is off.
• Lecture management points:
  • Mark the starting fluid level on the unit.
  • Keep the unit below the chest.
  • Gently milk the tubing toward the drainage chamber as needed.
  • Do not clamp the chest tube during transport.
• Subcutaneous emphysema: crackling under the skin (crepitus) around the site. Mark the edges and report it, because it means an air leak or a displaced tube. Spread to the neck can threaten the airway.
• Removal: the patient does a gentle Valsalva; cover the site with petrolatum gauze and a 4x4.
• Empyema: pus in the pleural space. Fever, chest pain, decreased breath sounds, and cloudy or foul drainage. Treated with drainage plus 4-6 weeks of antibiotics.
• Report at once: rapid shallow breathing, cyanosis, chest pressure, subcutaneous emphysema, signs of hemorrhage.
• Home teaching: stop smoking; keep doing coughing and deep breathing; report fever, more dyspnea, purulent sputum, or incision redness.

Non-Hodgkin Lymphoma

Read: Hinkle Ch. 30, lymphoma sections. Outline: nsg210-hinkle-ch30-hematologic-neoplasms. Leukemia and myeloma are in the same chapter but are not the focus here.

What to know:

• NHL vs Hodgkin:
  • NHL is far more common, has no Reed-Sternberg cells, and often spreads in a non-contiguous pattern, with extranodal sites.
  • Hodgkin has Reed-Sternberg cells, spreads node to node in a contiguous pattern, and peaks in young adults.
• Risk factors: immunosuppression (HIV, transplant drugs), autoimmune disease, older age, some viruses and chemicals.
• Signs:
  • Painless lymphadenopathy.
  • B symptoms: fever, drenching night sweats, weight loss over 10%.
  • Fatigue, pruritus.
• Diagnosis: lymph node biopsy, CT/PET, bone marrow biopsy, and staging.
• Treatment: chemotherapy (R-CHOP style regimens), monoclonal antibodies (rituximab), radiation, stem cell transplant.
• Nursing: infection prevention, tumor lysis watch at the start of treatment, managing chemo side effects, fertility counseling, and survivorship (long-term effects and second cancers).

From the lecture (Week 09, NHL lecture):

• Cells: most NHL is malignant B lymphocytes (textbook: 85% B cell).
• Who: incidence rises with each decade; median age at diagnosis is 66. Risks include immunodeficiency or autoimmune disease, prior cancer treatment, organ transplant, Epstein-Barr virus, HIV, and pesticides and other chemicals.
• Signs:
  • Early disease may have no symptoms.
  • Node swelling is noticeable by stage III or IV (textbook: painless, in the neck, armpit, or groin).
  • About one third have B symptoms.
• Masses press on organs:
  • A mediastinal mass causes respiratory distress.
  • An abdominal mass can compress a ureter and cause kidney problems.
  • An enlarged spleen causes early fullness, nausea, anorexia, and weight loss.
• Diagnosis: lymph node biopsy. Indolent types have small cells; aggressive types have large or immature cells. Staging is by CT and bone marrow biopsy.
• Treatment: radiation and chemotherapy.
  • Textbook: R-CHOP for aggressive disease.
  • Screen for hepatitis B before rituximab.
  • Watch for tumor lysis syndrome 12-72 hours after treatment starts.
• Nursing priorities:
  • Most care is outpatient.
  • Infection is the priority risk: teach how to lower it, the signs, and when to call.
  • Survivors need regular screening for second cancers. The ACS advice for survivors: no smoking, a normal BMI, fruits and vegetables, and at least 150 minutes of aerobic activity a week.

Vascular

PAD/PVD

Read: Hinkle Ch. 26. Outline: nsg210-hinkle-ch26-vascular-disorders.

What to know:

• ABI: ankle systolic pressure divided by brachial systolic pressure. Under 0.90 means PAD; under 0.50 means rest pain and severe disease. The slides and textbook give different cut-offs, so check the comparison page.
• Risk factors: smoking (the biggest modifiable one), diabetes, hypertension, hyperlipidemia.
• Treatment:
  • Walking program, stop smoking.
  • Antiplatelets (aspirin, clopidogrel), statins, cilostazol for claudication.
  • Revascularization (angioplasty or bypass).
• Teaching: no crossing legs, no heat pads on ischemic limbs (burn risk), meticulous foot care.
• After bypass:
  • Check pulses, color, temperature, and sensation often.
  • Sudden loss of pulse or pain means graft occlusion; notify the provider at once.
  • Avoid sharp knee or hip flexion.
• Acute arterial occlusion (the 6 Ps): pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia. This is an emergency.

From the lecture (Week 08, peripheral vascular lecture):

• Claudication appears at 50-70% occlusion and is felt about one joint level below the narrowed artery (calf pain points to the femoral or popliteal artery). Rest pain is worse at night and means severe disease.
• An absent pulse means the blockage is proximal to that point. Compare both sides.
• Color: pallor when the leg is elevated; dependent rubor (reddish-blue) within 20 seconds to 2 minutes of lowering it.
• ABI technique:
  • Use the higher arm pressure.
  • Use the higher of the dorsalis pedis and posterior tibial pressures for each leg.
  • ABI = highest ankle / highest arm.
  • Example: arm 140, ankle 84 gives 84 / 140 = 0.60 (claudication range).
• ABI cut-offs:

• Arteriogram care:
  • Before: consent, ask about iodine allergy, NPO after midnight.
  • After: bed rest 6 hours; check the puncture site, pedal pulses, and BP; encourage fluids.
• Teaching:
  • Legs below heart level.
  • Keep warm, but direct heat must not exceed body temperature.
  • No nicotine, no leg crossing, moderate exercise.
  • No lotion between the toes (maceration).
• Drugs:
  • Antiplatelets (aspirin, clopidogrel), statins, ACE inhibitors or ARBs.
  • Cilostazol for claudication is contraindicated in heart failure: question that order.
• After bypass (fem-pop, fem-tib, aortobifemoral):
  • A pulse or Doppler signal that disappears means graft occlusion: notify the surgeon immediately.
  • Avoid leg crossing and prolonged dependency; elevate to reduce edema.
  • Watch for compartment syndrome (severe edema, unrelenting pain, decreased sensation).
• Amputation (Other Exam 3 Reading):
  • Tourniquet at the bedside.
  • A pillow under the residual limb for the first 24 hours only, then prone positioning to prevent hip flexion contracture.
  • Figure-eight wrap to a cone shape; no oils or creams.
  • Phantom pain is real.

DVT and PE

Read: Hinkle Ch. 26, venous thromboembolism through pulmonary embolism (pp. 845-853). Hinkle Ch. 19 refers back to this section for PE.

What to know:

• Virchow triad: venous stasis, vessel wall injury, hypercoagulability. Risks include surgery (especially orthopedic), immobility, cancer, pregnancy and postpartum, estrogen, and central lines.
• DVT signs: unilateral swelling, pain, warmth, redness. Many patients have no signs. Diagnose with duplex ultrasound; D-dimer helps rule DVT out.
• Prevention: early ambulation, leg exercises, compression stockings, sequential compression devices, and prophylactic heparin or LMWH.
• Unfractionated heparin:
  • IV by weight-based protocol.
  • Monitor aPTT and platelets, because heparin-induced thrombocytopenia can occur.
  • Antidote: protamine sulfate.
• LMWH (enoxaparin): subcut. Do not expel the air bubble and do not rub the site.
• Warfarin:
  • Monitor INR, with a goal of 2-3 for VTE.
  • It overlaps with heparin until the INR is therapeutic.
  • Antidote: vitamin K.
  • Teach a consistent vitamin K intake.
• DOACs: apixaban, rivaroxaban, dabigatran. No routine monitoring. Reversal agents exist (andexanet alfa, idarucizumab).
• Bleeding precautions with all anticoagulants.
• PE:
  • Sudden dyspnea and tachypnea (the most common signs), pleuritic chest pain, tachycardia, anxiety, hypoxemia.
  • CT pulmonary angiography is the diagnostic standard.
  • Emergency response: raise the head of the bed, give oxygen, call for help, and start anticoagulation. Thrombolytics are used for massive PE.

From the lecture (Week 08, peripheral vascular lecture):

• Risk factors (slide list):
  • Immobility or bed rest, recent surgery or hospitalization, major trauma.
  • Prior DVT or PE, cancer, pregnancy and postpartum, estrogen.
  • Obesity, smoking, thrombophilia, increasing age.
  • In the history, also ask about varicose veins and cardiovascular disease.
• DVT signs:
  • Only about half of patients have symptoms, and they are nonspecific. Homans sign is not reliable.
  • Compare leg circumference from thigh to ankle, and check for warmth and tenderness.
  • Duplex ultrasound and D-dimer.
• Heparin and warfarin:

• Warfarin is started together with heparin; it takes about a week to work.
• LMWH (enoxaparin): subcut, can be self-given, longer half-life, fewer bleeding complications.
• Heparin-induced thrombocytopenia (HIT): platelets under 100,000 or a drop of more than 25% (for example, 240,000 to 150,000). Notify the provider; argatroban is used instead. Petechiae and bruising come first.
• Labs to follow: PTT, PT/INR, H&H, platelets, fibrinogen. Watch for LOC changes and blood in urine, stool, skin, and nose.
• Other treatments:
  • Thrombolytics work best within 3 days of the clot, with more bleeding risk.
  • Thrombectomy or a vena cava filter when anticoagulation cannot be used.
• Prevention and bed rest:
  • Reapply compression stockings before the legs are lowered in the morning.
  • A patient with DVT on bed rest keeps the legs elevated and does calf exercises.
• Superficial thrombophlebitis rarely embolizes: warm compresses, elevation, NSAIDs. A DVT can become a PE.
• PE signs:
  • Sudden dyspnea, tachypnea, tachycardia, pleuritic chest pain.
  • Anxiety or a sense of impending doom, cough, hemoptysis, syncope, sweating, low SpO2.
  • Hypotension if severe.
• PE ECG (textbook): sinus tachycardia and nonspecific ST-T changes, which do not diagnose PE. CT pulmonary angiography is the standard.
• PE nursing priorities: airway and breathing, SpO2, heart rate and rhythm, BP, LOC, anxiety, and signs of DVT.

Rheumatic and Joint Disorders

Outlines: nsg210-hinkle-ch34-inflammatory-rheumatic-disorders, nsg210-hinkle-ch36-musculoskeletal-disorders.

SLE

Read: Hinkle Ch. 34, pp. 1082-1089.

• What it is: a systemic autoimmune disease, most often in women of childbearing age. It flares and remits.
• Signs:
  • Butterfly (malar) rash and photosensitivity.
  • Arthralgia, fatigue, fever.
  • Raynaud phenomenon, oral ulcers, pleuritis and pericarditis.
• Lupus nephritis is a major cause of illness and death. Monitor BP, weight, urine output, proteinuria, and creatinine.
• Labs: ANA is positive in over 95% (sensitive). Anti-dsDNA and anti-Smith are specific.
• Treatment:
  • NSAIDs.
  • Hydroxychloroquine (needs eye exams).
  • Corticosteroids (lowest dose, shortest time, never stop abruptly).
  • Immunosuppressants (methotrexate, azathioprine, cyclophosphamide, mycophenolate) and belimumab.
• Teaching: sun protection, infection prevention, rest and pacing, recognizing flares, and planning pregnancy (most immunosuppressants are teratogenic).

From the lecture (Week 08, rheumatic diseases lecture):

• Triggers:
  • Hormonal (onset in the childbearing years) and sunlight or UV light.
  • Drugs: isoniazid, hydralazine, antiseizure drugs (drug-induced lupus).
• Other features: discoid rash (red scaly papules), extreme fatigue, CNS effects (depression, memory problems), atherosclerosis risk in women, low blood counts.
• Diagnosis (slides): ACR criteria, 4 of 11. The textbook instead stresses ANA (positive in over 95%) and anti-dsDNA and anti-Sm.
• Management: NSAIDs, corticosteroids, hydroxychloroquine; immunosuppressants only if conservative care fails; belimumab.
• Teaching:
  • Avoid sun and UV light (sunscreen, protective clothing).
  • A diet high in vitamins and iron.
  • Watch for bruising and bleeding; support groups.
• Lupus nephritis flare (lecture case): fatigue, joint pain, facial and ankle edema, weight gain, high BP, foamy urine (protein), hematuria, low urine output, rising creatinine and BUN. It was triggered by stopping steroids and by sun exposure. Case lessons:
  • Priority finding: urine output under 30 mL/hr with a rising creatinine (acute kidney injury). The rash and joint pain are expected.
  • Daily weights track fluid retention; 1 kg is about 1 L.
  • Never stop corticosteroids abruptly (adrenal insufficiency, flare). Taper only as ordered.
  • UV light triggers systemic flares, not just the rash, so sun protection is needed even without a rash.
  • Fever, a new cough, and a low WBC in an immunosuppressed patient mean possible serious infection. Address that first.

Gout

Read: Hinkle Ch. 34, pp. 1089-1092.

• What it is: uric acid crystals deposit in joints. The classic attack is sudden, severe, red, and hot, often in the great toe at night. Chronic gout causes tophi and kidney stones.
• Triggers: purine-rich foods (organ meats, shellfish, some fish), alcohol (especially beer), fructose drinks, thiazide and loop diuretics, low-dose aspirin, dehydration, and CKD.
• Acute treatment: NSAIDs, colchicine (diarrhea is the early toxicity sign), corticosteroids. Rest and elevate the joint.
• Long-term treatment: allopurinol or febuxostat lower production; probenecid raises excretion (needs fluids). Do not start urate-lowering drugs during an acute attack.
• Teaching: a low-purine diet, limit alcohol, 2-3 L of fluid a day, and weight loss.

From the lecture (Week 08, rheumatic diseases lecture):

• Hyperuricemia: the slides say over 7 mg/dL; the textbook says over 6.8.
• Attacks follow sudden rises or falls in uric acid. Severe dieting or starvation and decreased kidney excretion are also causes.
• Tophi can drain a yellow, gritty material. Kidney urate deposits cause stones and can cause kidney failure.
• Diagnosis: needle-shaped, negatively birefringent crystals in joint fluid. Uric acid, WBC, and ESR are elevated.
• Drugs:
  • Colchicine: for acute attacks. Long-term use lowers vitamin B12 absorption.
  • Allopurinol: long-term maintenance; watch for bone marrow depression. Start it after the acute attack resolves.
  • Probenecid: increases urinary excretion; nausea, rash, constipation.
• Thiazide diuretics raise uric acid. Discuss alternatives with the provider. CKD lowers uric acid excretion.
• Lecture case:
  • Profuse diarrhea, cramping, and vomiting after colchicine means toxicity: hold the colchicine and notify the provider.
  • High fever with hypotension, or purulent joint fluid, points to septic arthritis or sepsis, not gout.
  • Classic gout is one red, hot, swollen joint (usually the great toe) that cannot bear the bedsheet. Painless bilateral ankle swelling is not gout.

RA and OA

Read: RA, Hinkle Ch. 34, pp. 1078-1082. OA, Hinkle Ch. 36, pp. 1122-1124.

From the lecture (Week 08, rheumatic diseases lecture):

• Pannus is inflamed granulation tissue that destroys cartilage and bone in RA. OA is degeneration, with inflammation only secondary.
• No single lab confirms a rheumatic disease. RF is positive in 80% of RA. Anti-CCP is 95% specific and detects RA earlier. Expect a high ESR and low RBCs.
• RA joints: spongy, soft joints; morning stiffness over 1 hour; bilateral and symmetric. Extra-articular signs include rheumatoid nodules and Sjogren syndrome (dry eyes and mouth). Treat early and aggressively.
• Drug cautions:

• Nonpharmacologic care:
  • Heat and cold, assistive devices, individualized exercise.
  • A mild analgesic before activity.
  • Short-term low-dose amitriptyline for sleep.
  • Joint protection teaching.
• Older adults: arthritis is not an inevitable part of aging. Drug side effects are more likely.

Total Knee Replacement

Read: Hinkle Ch. 36, pp. 1124-1135 (the patient undergoing arthroplasty, p. 1124; TKA, p. 1134).

• Indications: severe pain and lost function from OA or RA when conservative treatment fails.
• Before surgery: baseline neurovascular and functional status, treat any infection first (dental, urinary, skin), and teach exercises and the plan.
• After surgery:
  • Neurovascular checks (color, warmth, pulses, sensation, movement).
  • Drain and bleeding watch.
  • Pain control timed before physical therapy.
  • Early mobilization with weight bearing as ordered.
• Continuous passive motion (CPM) if ordered, plus exercises to reach knee flexion of about 90 degrees.
• Positioning:
  • Do not put a pillow under the knee; it causes a flexion contracture. Keep the leg straight and elevate the whole limb.
  • (Hip precautions against adduction and flexion over 90 degrees apply to hip replacement, not knee.)
• VTE prevention is a priority: anticoagulant prophylaxis, SCDs, ankle pumps, early ambulation. Know DVT and PE signs.
• Infection:
  • Watch for fever, increasing pain, wound drainage, or redness.
  • Prophylactic antibiotics before dental and other invasive procedures per provider.

From the lecture (Week 08, rheumatic diseases lecture, slides 28-30):

• Types:
  • Total hip: femoral head and acetabulum.
  • Total knee: femur, tibia, sometimes patella.
  • Also shoulder, partial, and revision (a redo for loosening, wear, infection, or failure).
• Indications: persistent pain, impaired mobility, and declining ADLs when conservative care fails. Causes include OA, RA, trauma or fracture, and avascular necrosis (especially the hip).
• Nursing:
  • Before surgery: establish a baseline, identify risks, and prepare the patient physically and emotionally.
  • After surgery: prevent complications (VTE, infection, dislocation for hips) with neurovascular checks.
  • The slides point to the textbook for the details above.

Calculations

Practice the standard med-surg dosage calculations, especially the ones that go with this unit:

• Heparin infusions: units/hr to mL/hr, and weight-based boluses and rate changes from a protocol.
• Enoxaparin weight-based dosing.
• IV flow rates (mL/hr and gtt/min).
• Tablet and liquid oral doses.

Formulas used in the course:

Worked examples:

• Drip rate: heparin 25,000 units in 500 mL is 50 units/mL. An order for 1,200 units/hr runs at 1,200 / 50 = 24 mL/hr. The common error is dividing the other way (25,000 / 1,200).
• Bolus: an 80 units/kg bolus for a 154 lb patient. 154 / 2.2 = 70 kg; 80 x 70 = 5,600 units; from 1,000 units/mL that is 5.6 mL. Convert pounds to kg first, and do not confuse the bolus with the hourly drip dose.
• Drops per minute: 500 mL over 4 hours with 20 gtt/mL tubing. 500 / 240 min x 20 = 41.7, so 42 gtt/min. mL/hr (here 125) is not the same as gtt/min.

Postpartum, Newborn, and Women’s Health

Read: Durham Ch. 12-19. Lecture notes: nsg210-week-10-postpartum-newborn-lecture; expanded class notes: nsg210-week-10-class-notes.

OB topic areas, with where to read:

Main topics:

• Postpartum: involution and fundal checks, lochia, PPH (atony first), subinvolution, cesarean recovery, breastfeeding and engorgement, Rubin’s phases, and blues vs depression vs psychosis.
• Newborn: transition, Apgar, S.T.A.B.L.E., Ballard score, erythromycin and vitamin K, screenings, cold stress, jaundice types, MAS vs RDS, NEC, NAS, birth defects.
• Women’s health: menstrual disorders, PCOS, endometriosis, prolapse, infertility, contraception, menopause, STIs, breast and reproductive cancers.

From the lecture (Week 10, OB lecture and class notes), by topic:

Maternal and Physiological Adaptations

• Fundus:
  • Halfway between the symphysis and the umbilicus right after delivery.
  • At or 1 cm above the umbilicus at 1 hour, then down about 1 cm a day.
  • In the pelvis by day 14; back to pre-pregnancy size by about 6 weeks.
• Fundal checks: every 15 minutes for 1 hour, every 30 minutes for 1 hour, every 4 hours to 24 hours, then every shift.
• A boggy, displaced fundus: a full bladder displaces the uterus and causes atony, so have her void.
• Lochia: rubra (red, days 1-4), serosa (pink-brown, days 4-10), alba (white, after day 10). A foul odor means infection.
• Vital signs:
  • Temperature up to 0.5 C higher in the first 24 hours is normal.
  • A rise on days 3-4 can be engorgement.
  • Fever after day 3 means infection until proven otherwise.
• Systems:
  • Diuresis starts on day 2, up to 3,000 mL/day.
  • The hypercoagulable state lasts 8-12 weeks, so embolism risk stays up.
  • Constipation and reflux improve in 3-4 days.
• Assessment: BUBBLE-HE (breasts, uterus, bowel, bladder, lochia, episiotomy or laceration, Homans/legs, emotions) at each assessment.
• Perineal care:
  • Lacerations are graded 1st to 4th degree; a 3rd-degree tear reaches the anal sphincter, a 4th-degree tear the rectal mucosa.
  • Ice for 10-20 minutes, sitz baths, witch hazel pads, peri-bottle front to back, stool softener.
• Rubin’s phases (emphasized in lecture):
  • Taking-in, the first 3 days: focused on her own needs and on retelling the birth. Not the time to teach.
  • Taking-hold, days 4-10: takes on infant care. The best time to teach.
  • Letting-go: accepts the new role.
  • Cues: “wants to talk about the delivery” is taking-in; “asks how to bathe the baby” is taking-hold.
• Bonding vs attachment:
  • Bonding is the mother’s feelings toward the infant, over hours to weeks.
  • Attachment is the child’s bond to the caregiver, over a longer time.
• Lactation:
  • Colostrum for the first 2 days; mature milk by about day 3; engorgement on days 3-5.
  • 8-12 feedings in 24 hours. Feed at early hunger cues; crying is late.
  • A good latch takes part of the areola and does not hurt. Break suction with a finger.
  • Exclusive breastfeeding for 6 months; it needs about 700 extra kcal a day.
• Return of fertility and contraception:
  • Non-breastfeeding mothers get menses back in 6-8 weeks.
  • Breastfeeding mothers usually take 4-5 months or longer for menses, though ovulation can return by about 6 weeks.
  • Breastfeeding: progestin-only contraception after 6 weeks, because estrogen reduces supply.
  • Not breastfeeding: no estrogen before 3 weeks (clot risk).

Postpartum Complications

• PPH: 1,000 mL or more cumulative, or blood loss with hypovolemia, within 24 hours of birth.
  • The most common cause is uterine atony (a boggy uterus).
  • Rule of 30: a 30% fall in Hct, a 30 mm Hg fall in systolic BP, or 30% blood loss.
  • Tachycardia and hypotension are late signs, meaning 1,500 mL or more lost.
• PPH escalation:
  • Fundal massage and empty the bladder.
  • Uterotonics: oxytocin, methylergonovine, misoprostol, carboprost.
  • Then tamponade, then tranexamic acid (cuts deaths when given within 3 hours of birth), then the massive transfusion protocol.
  • Rapid transfusion can cause hypocalcemia.
• Subinvolution: the uterus fails to shrink because the placental-site vessels do not close.
  • Causes: retained fragments, infection, an overdistended uterus.
  • Signs: prolonged bleeding, pain, back pain.
• Endometritis: heavy bleeding with uterine tenderness and fever.
• Cesarean recovery:
  • Complications: infection, hemorrhage, DVT and PE, ileus, spinal headache.
  • Priority is ABCs, then deep breathing and incentive spirometry.
  • After neuraxial morphine, monitor sedation and respirations.
  • SCDs for VTE prevention. Do not massage a leg with a suspected DVT.
• Mood disorders:

• Screening: EPDS (0-30) leaves out fatigue and appetite, which overlap with normal recovery. The slides’ bands overlap, so see the comparison page. PHQ-9 runs 0-27.

Newborn Assessment and Priorities

• Apgar at 1 and 5 minutes. Heart rate is the most important sign; color is the least reliable.
• S.T.A.B.L.E.:
  • Sugar 25-110 mg/dL at 1-2 hours, then 60-100.
  • Temperature 96.8-99.5 F.
  • Airway: RR 40-60, periodic breathing is normal, grunting is a warning sign.
  • BP 60-80/30-45.
  • Labs: the metabolic screen.
  • Emotional support for the family.
• Hypoglycemia risk: infants of diabetic mothers, SGA, LGA, preterm, cold-stressed.
• Exam:
  • Count fingers and toes (polydactyly, syndactyly).
  • Palate intact.
  • Check for hypospadias and undescended testes.
  • Anus patent, with meconium in 24-48 hours. No rectal temperatures.
• Reflexes: the Moro is the most tested; a one-sided Moro suggests a clavicle fracture or brachial plexus injury. A positive Babinski is normal in a newborn.
• Ballard score: physical maturity within 2 hours, neuromuscular within 24 hours.
• Medications:
  • Erythromycin eye ointment and IM vitamin K: Durham says within 1 hour; the slides say 24 hours (eye) and 6 hours (vitamin K).
  • Vitamin K must be given before circumcision.
• Screens:
  • Metabolic screen between 24 and 48 hours of age, after feeding has started so PKU is not missed.
  • Hearing screen.
  • CCHD screen by pulse oximetry.
• Circumcision: do not circumcise with hypospadias or epispadias (the foreskin is saved for the repair). Other contraindications: bleeding disorders, a sick or preterm infant, ambiguous genitalia.

Complications of the Neonate

• Cold stress: the newborn cannot shiver and burns brown fat, which leads to hypoxia, hypoglycemia, and metabolic acidosis. Dry the infant, cover the head, and use skin-to-skin contact or a warmer.
• Birth weight:
  • LBW is under 2,500 g, VLBW under 1,500 g, ELBW under 1,000 g, HBW over 4,000 g.
  • SGA is under the 10th percentile and LGA over the 90th.
  • Asymmetric IUGR (head sparing, from placental insufficiency) is more common than symmetric IUGR (early insult).
• Jaundice:
  • Jaundice in the first 24 hours is pathologic.
    • Rh or ABO hemolysis, infection.
    • Bilirubin rising more than 5 mg/dL a day or totaling over 15.
  • Physiologic jaundice appears after 24 hours and peaks on day 4.
  • Breastfeeding jaundice is early, from too little intake; feed more often.
  • Breast milk jaundice peaks at days 10-14.
• MAS vs RDS:
  • Meconium aspiration affects term and post-term infants; the X-ray shows atelectasis with hyperinflation.
  • RDS affects preterm infants (surfactant deficiency). Grunting, flaring, retractions, and RR over 60; a ground-glass X-ray. Treat with surfactant and keep NPO.
• NEC: preterm infants in the first 2 weeks.
  • Feeding intolerance, bilious vomiting, distension, bloody stools.
  • Air in the bowel wall on X-ray.
  • NPO and an NG tube are the key treatment, plus TPN and antibiotics.
• Neonatal abstinence syndrome:
  • Onset: alcohol 3-12 hours, narcotics 48-72 hours, barbiturates days 1-14.
  • Signs: high-pitched cry, tremors, increased tone, excessive sucking, sneezing, diarrhea.
  • Opioid withdrawal: methadone, morphine, clonidine, phenobarbital.
  • Breastfeeding is allowed with maternal methadone.
• Fetal alcohol syndrome: facial anomalies, heart defects, cognitive and behavioral problems.

Birth Defects

The textbook covers these only briefly, so the slides (60-68) and class notes are the main source.

• Cleft lip and palate: forms at 4-12 weeks of gestation.
  • Repair: lip at 1-3 months, palate at 12-18 months (before speech).
  • Feeding: feed upright with special nipples, small frequent feeds, burp often; watch for aspiration.
  • After any repair: minimize crying.
  • After lip repair: on the back or side, never prone; elbow restraints.
  • After palate repair: nothing in the mouth (no straws, pacifiers, or spoons).
• Duodenal atresia: the most common intestinal atresia.
  • Bilious, projectile vomiting in the first 24-36 hours, often after the first feed.
  • “Double bubble” on X-ray.
  • Linked to polyhydramnios and trisomy 21.
  • Green vomit in a newborn is a surgical emergency: stop feeds and notify.
• Esophageal atresia with TEF:
  • The 3 Cs (coughing, choking, cyanosis with feeding), drooling, and an NG tube that will not pass.
  • NPO, suction the pouch, head elevated.
• Omphalocele vs gastroschisis:

• Immediate care (both):
  • Cover with sterile, warm, moist saline dressings and plastic wrap (or a bowel bag), without pressure.
  • Support the bowel so it does not kink.
  • Radiant warmer and IV fluids (heat and fluid loss).
  • NPO with an OG or NG tube to suction; antibiotics.
• Neural tube defects: form in the first month, often before the pregnancy is known.
  • Spina bifida occulta: a bony gap only, no disability. Skin clues are a dimple, hair tuft, or birthmark.
  • Meningocele: a sac without cord involvement.
  • Myelomeningocele: the most common and most severe form, with cord in the sac. It causes paralysis and bladder and bowel dysfunction, and often hydrocephalus.
  • Anencephaly: parts of the skull and brain are missing.
  • Folic acid lowers the risk. Risk rises with valproate, carbamazepine, uncontrolled diabetes, and obesity.

Infertility and Menstrual Disorders

• Amenorrhea: primary means no menarche by 15. Secondary means 3 months without menses after normal cycles; the most common cause is pregnancy.
• Endometriosis: endometrial tissue outside the uterus. Ages 30-40; pain, dyspareunia, infertility. NSAIDs, oral contraceptives, surgery.
• PCOS:
  • Anovulation, obesity, insulin resistance, hirsutism, cysts.
  • The most common cause of female infertility.
  • Higher risk of endometrial cancer from unopposed estrogen.
• Abnormal uterine bleeding: causes include fibroids, endometrial cancer, and infection.
• PMS vs PMDD: PMDD is severe depression, anxiety, and lability in the luteal phase.
• Fibroids (leiomyomas): benign smooth muscle tumors of the uterine wall that cause heavy bleeding and dyspareunia. Slide 85 defines them with the endometriosis wording, which is a slide error.
• Infertility: no pregnancy after 1 year of unprotected intercourse.
  • Female: PID (usually chlamydia or gonorrhea) is the leading cause of tubal infertility; also PCOS, endometriosis, fibroids, and age.
  • Male: varicocele is the most common correctable cause. Also cryptorchidism, Klinefelter syndrome, mumps, and chemotherapy.
  • Testicular torsion must be corrected within 6 hours.

Women’s Health and Alterations

• Pelvic organ prolapse:
  • Types: cystocele (bladder), rectocele (rectum), enterocele (small bowel), uterine prolapse.
  • Symptoms: pressure, voiding problems, constipation.
  • Treatment: Kegel exercises, vaginal estrogen, a pessary, surgery.
• Contraception:
  • The IUD is the most effective reversible method; cramping and spotting at first are normal.
  • Do not massage the Depo-Provera site; it is given every 3 months.
  • No estrogen pills with a history of clots, smoking, hypertension, or CV disease.
  • Leave the sponge or diaphragm in 6 hours after intercourse, and remove the sponge by 24-30 hours (toxic shock).
  • Emergency contraception works up to 5 days after (copper IUD, ulipristal, levonorgestrel).
• Menopause: 12 months without menses, usually around 50.
• STIs:
  • Chlamydia is the most common and often silent; it causes PID and ectopic pregnancy.
  • Gonorrhea is the second most common.
  • Herpes is treatable but not curable, and dangerous to newborns.
  • HPV causes warts and cervical dysplasia. The vaccine is given at 11-12, with catch-up through 26 for females.
• Breast cancer: invasive ductal carcinoma is the most common type. Signs: a lump, dimpling, nipple discharge or new inversion. Mammogram every 1-2 years from 40 to 75 at average risk.
• Reproductive cancers:
  • Endometrial: abnormal or postmenopausal bleeding; risk from unopposed estrogen.
  • Cervical: persistent HPV.
  • Ovarian: vague bloating and early fullness.
  • Testicular: ages 15-35, a painless lump.

Other Exam 3 Reading

These chapters are in the Exam 3 reading set but are not among the topics above:

• Amputation: Hinkle Ch. 37, outline, and the peripheral vascular lecture.
• Musculoskeletal assessment: Hinkle Ch. 35, outline.