MOTHER/BABE/ FAMILY CARE

-First Trimester: 1-12 weeks, heart, spinal cord, nail beds, spontaneous movements, reflexes present, bone forming,
heartbeat audible by Doppler, bones and teeth forming, kidney forming, Parent needs to accept pregnancy
-Second Trimester: 12-24 weeks, earing, eyes, pupils, lids work, passive immunity transferred from mom at 2! weeks,
lung surfactant present, developed biorhythms, heartbeat audible, brown fat, liver and heart functioning" Parent needs to
accept baby
-Third Trimester: #24-4! weeks$, kicks, vernix caseosa fully formed, creases on soles of feet, fetal hemoglobin starts to turn
to adult hemoglobin #about 2!%$, &' fat, lanugo decreases, turn head down" Parent needs to accept parenthood"
-'ommon emotional responses are( ambivalence grief, narcissism #self-centered$, introversion, extroversion, stress, couvade
syndrome #men getting the nausea, vomiting, and backache$, body image and boundary confusion, emotional labilitym and
changes in sexual desire"
-McDonad!s R"e: method of determining fetal growth by measuring fundal height from notch of symphasis pubis,
accurate only between 2!-)1
st
weeks,
-Monitor: 1$*etal heart rate #between 12!-1+!$, 2$*etal movement, )$ ,ltrasound 4$ -'./s 0$ 123
+$amniocentesis 4$Percutaneous umbilical cord sampling
Com#ications o$ %re&nanc'
-(a&ina Beedin&(may lead to hypovolemic shock, could be cause by miscarriage, ectopic preg, premature cervical dilation,
placenta previa, premature separation of placenta, preterm labor"
-#ersistent )omitin&* chis and $e)er #3nteruterine infection5$,
- s"dden shar# increase in +t, near the end of preg 6 water retention or beginning of preeclampsia
-s"dden esca#e o$ cear $"ids $rom the )a&ina, #ruptured membranes, uterine cavity no longer sealed against infection,
umbilical cord may prolapse, fatal head no longer fits snugly, women may confuse this with stress incontinence"
-a-domina or chest #ain: ,terus expands painlessly, may be ectopic pregnancy, placenta separation, preterm labor,
appendicitis, ulcer, pancreatitis, P-
increase or decrease in $eta mo)ement*
e.#os"re to terato&ens #cigarettes, alcohol, radiation, lead, tetracycline, hyper7hypothermia$( 892' tool stands
toxoplasmosis, rubella, cytomegalovirus, herpes" /o/ stands for other infections, such as syphilis, hep :, 3;,
H'dramnios( excessive amniotic fluid, can cause fetal malpresentation, premature rupture of membranes, preterm labor,
prolapsed cord,
%ost-term #re&nanc': longer than 42 weeks, can be caused by taking salicylates fro headaches or 2<, can lead to
meconium aspiration, baby may get to big to pass thru canal, or can lead to lack of growth, lack of 92, nutrients fluid
%se"doc'esis: false pregnancy symptoms in non-pregnant people"
- Isoimm"ni/ation 0Rh incom#ati-iit'1: 1om who is 2h- carrying 2h= baby, as dad is 2h=" 2h is an antigen, so when
baby who is 2h positive passes the blood to mom, she is invaded by foreign agent #antigen$" 1om/s body reacts and forms
antibodies to the antigen, 8hese antibodies pass into fetal blood and destroy the whole red blood cell where 2h lives" 8his
can cause hemolytic disease in newborn" 1om/s blood only is exposed to fetus/s blood if villi rupture, during amniocentesis,
but a lot of blood exchange during birth, so these antibodies are formed after birth in the first 42 hours"
-%re&nanc' ind"ced h'#ertension 0%ID1, #aka 8oxemia$ ( >here ;asospasm occurs during pregnancy, " 0-1!% of all
pregnancies" ?9 known cause, 9ccurs more in primiparas and women under 2! or over 4!, &ymptoms( %rotein"ria* 2apid
wt" .ain, swelling of face7fingers, flashes of light7dots behind eyes, blurred vision, headache, decreased urine output"
'lassified as
21 &estationa h'#ertension: :P over 14!7@!, no proteinuria, or edema,,, low dose aspirin, may develop 8? later in life
AAA ?ursing interventions for women with mild hypertension( Promote bed rest, good nutrition #decreased salt$, Provide
emotional support,
31 mid #re-ecam#sia: 14!7@!, has proteinuria =1 or =2, may have edema"
AAA ?ursing 3nterventions= Promote bed rest, monitor maternal well-being, monitor fetal well-being, support nutritious
diet, administer meds #antihypertensives I( ma&nesi"m s"$ate*
41se)ere #re-ecam#sia: :P over 1+!711!, Proteinuria =) or =4, severe edema, epigastric pain, ?=;, &9:, blurred vision,
headache
51ecam#sia: Sei/"re or coma occurs d7t cerebral edema, 2!% mortality d/t renal failure, circ collapse, cerebral emorrhage,
fetus usually dies d7t acidosis
AAA ?ursing( 8onic-'lonis seiBures, maintain airway assess o2, turn on side, apply fetal heart monitor, check for vag
bleeding, birth may be induced, may have post-partal hypertension"
?ot all three need to be present for diagnosis, hypertension and proteinuria most significant" -dema only sig" 3f increased
:"P C proteinuria or signs of multi organ system involvement"
AAA< systolic blood pressure greater than )! mmg and diastolic :"P greater than 10 mmg is a helpful rule due to varying
:"P in women"
?ursing 3nterventions( :ed rest
-always in the lateral recumbent position to avoid uterine pressure on the vena cava C to prevent supine hypotension
syndrome"
.ood nutrition, #increased protein and moderate sodium diet$" -motional support" >ith eclampsia- monitor fetal well-being
with Doppler"3f a seiBure occurs maintain a patent airway and administer oxygen"
;alium as an emerg" 1easure"
HELL% SY6DROME
-variation of P3"
-&tands for hemolysis elevated liver enBymes and low platlets"
S7S
-nausea
-epigastic pain
-malaise
-2,D pain
-lab results hemolysis of 2:'
-increased liver enBymes due to hemorrhage #observe for bleeding$"
8reatment( transfusion of plasma and platlets
'omplications of -EEP( liver hematoma, hyponaturemia, renal failure C hypoglycemia
0$ Ine$$ecti)e 8terine contractions: #hypotonic, hypertonic, uncoordinated$
+$ Contraction rin&s: constriction ring, where there is a horiBontal indentation across abdomen from excessive retraction of
upper uterine segment"
4$ %reci#itate a-or: when contractions are so strong, baby is born in fewer than ) hours, may lead to premature separation
of placenta, hemorrhage, fetal subdural hemorrhage
F$ 8terine r"#t"re: occurs usually when an old scar from past c-section tears, or prolonged labor, multiple gestation,
obstructed labor etc" >omen will feel severe sudden pain" 8ear can be through one or all layers" Eook for signs of shock,
hemorrhage"
@$ %roa#sed 8m-iica cord: loop of the umbilical cord slips out before baby" Eeads to cordal compression, <dmin 92,
1!$ drop in :P6 could be caused by baby/s pressure on vena cava" Position mom on left lateral side and re-check :P
Sta&es o$ La-or and Dei)er'
First Sta&e:
a1 Latent sta&e:
begins at onset of regularly perceived uterine contractions and ends when rapid cervical dilation begins"
'ontractions are mild and short #2!-4! seconds$"
'ervical effacement occurs, and dilates from !-) cm
Easts approx" + hours in nullipara, and 4"0 in multipara
-1 Acti)e sta&e:
further cervical dilation from 4-4 cm
contractions now 4!-+! seconds every )-0 minutes
lasts ) hours in nullipara, and 2 hours in multipara show and rupture of membranes may occurs
now is when analgesic should be administered"
c1 Transition #hase:
dilation F-1! cm
contractions peak every 2-) minutes, lasting +!-@! seconds
if not done already, membranes will rupture at 1! cm as a rule
show will be present, last of mucous plug from cervix released
cervix now effaced and obliterated
primary need here is pain controlGG
Second sta&e:
the period from full dilation and cervical effacement to birth
contractions change to urge to push
fetus in pelvis and crowning
Third Sta&e:
<fter infant is born, the uterus can be palpated as firm round mass , after a few minutes of rest, uterine contractions begin
again, and uterus assumes a disc shape until placenta has separated, approx 0 minutes after birth"
a1 %acenta Se#aration
occurs automatically as the uterus resumes contractions
active bleeding on maternal surface of the placenta starts, and helps to separate the placentaby pushing it away from
attachment site"
8he following signs show placenta has loosened and is ready to deliver
1$ lengthening of umbilical cord
2$ sudden gush of vag" blood
)$ change in shape of uterus
?ormal blood loss is )!!-0!! mE/s
-1 %acenta E.#"sion
placenta delivered by bearing down or gently pressing on fundus
?ever put Pressure on uterus in noncontracted state, l7t hemorrhage
Assessment o$ a-orin& mom
21 Feta Heart Rate: #normal between 11!-1+!$
31 Meconi"m stainin&: fetal hypoxia5, normal in breech presentation" 2eport immediately
41 $eta h'#eracti)it': H'#o.ia9
51 $eta acidosis
:1 Mom!s hi&h/o+ B%
;1 Mom!s a-norma #"se: hemorrhage
<1 inade="ate or on& contractions
>1 mom has $" -adder: stops baby/s head from decending, may inHure bladder
?1 Leo#od!s mane")er : palpating abdomen to determine fetal position and presentation
2@1 (a&ina e.am
221 Assessments o$ contractions: Eength, 3ntensity, *reIuency
Para 8he number of pregnancies that reached viability, regardless of whether the infants >ere born alive or not"
.ravida < women who is or has been pregnant
Primigravida < women who is pregnant for the first time
Primipara < women who has given birth to one child past the age of viability
1ultigravida < women who has been pregnant before
1ultipara < women who has carried two or more pregnancies to viability
?ulligravida < women who has never been and is not currently pregnant
O.'tocin 0#itocin1
-31 or 3; to increase contractions and minimiBe bleeding
obtain baseline :P, as it causes hypertension, don/t use on women with prior hypertension
can be continued upto F hours after birth to ensure contractions
Common #ain meds $or a-or
Narcotics (IM/IV) Lumbar epidural Pudendal block
demerol marcaine Eocal, eg" lidocaine
morphine naropin
fentanyl 'an add morphine or fentanyl
Assessment o$ 6e+ Mom
-puerperium or post-partal period is the + weeks after delivery
Jassess for the taking in, taking hold and letting go phases"
immediately assess vitals, uterine fundal height, lochia characteristcs, urinary and bowle system,evidence of perineal
healing, physical activity"

In)o"tion: is process where reproductive organs return to non-preg state"

*irst, area where placenta was seals off, then uterus reduced in siBe"
-8he fundus of uterus immediately after birth is halfway between umbillicus and symphysis pubis"
9ne hour later it is at level with umbilicus, where it stays for 24 hours
from then on, it will decrease 1 cm #fingerbreath$ per day
eg" *or first day post-partal, it is palpated one cm below umbilicus, on day 2= 2 cm below, and by the @
th
or 1!
th
day, it is
withdrawn into the pelvis and can/t be palpated,
?ever palpate fundus without supporting lower segment
uterus of breastfeeding women contract faster due to oxytocin"
<ssess after bladder is emptied" 1ay be found slightly to the right d7t colon"
<fterpains are contractions after birth, are good, as uterine atony means no throbus have formed and therefor can lead to
hemorrhage"
1ay massage fundus until firm, or apply ice to perinium
-Lochia: consists of blood, >:', bacteria, mucous, and part of placental wall"
*or the 1
st
three days( lochia rubra6 mostly blood
by 4
th
day( lochia serosa6 more leukocytes, pink7brown )-1! days, mucous
by 1!
th
day( lochia alba6 white, mucous, >:', decreased flow, lasts )-+ weeks"
<mount will vary among women" 8here should be no large clots and no offensive odor" 3t should be present for about 1-)
weeks and anything more then 1 soaked pad per hour should be investigated"
Breasts: %re)ention/ae)iate -reast en&or&ement
-allow baby to suckle freIuently #main treatment for tenderness7soreness$
-application of warm compresses or a warm shower
-good support bra
-cold compresses applied )-4 times daily during engorgement
-analgesics, creams
%romote Breast H'&iene
-care should be directed at cleanliness and support
-wash breasts daily with clear water and dry
-soap should be avoided because it causes dryness and cracked nipples
-use of gauBe or bra pads to absorb colostrums7milk
-encourage mother to continue with self- breast exams monthlysecreting colostrum from
-on day three, breast become full of milk from response of fall in estrogen and progesterone levels

E#isiotom'
( turn women into sims position with back towards you and assess perineum, observe for eccymosis, hematome, erythema,
edema, intactness, drainage, bleeding
-episiotomy usually 1-2 inches long"
-may have soothing cream, sotx bath witch haBel preparations
%re-o# Assessment o$ C-section Mom
-interference with self-esteem( scars
-stress response( increased 2, bronchial dilation, increased :lood glucose, increased :P
->omen/s knowledge of procedure #ie" Eength of stay, catheter, 3;$
-9perative risk , age, fear
-Poor nutritional status( 9besity6 increased infection, dehiscence, poor heart, difficulty turning
-8eaching( deep breathing, incentive spirometry, turning, ambulation
-3nformed consent5
-pre-op hygiene, enema, skin prep, admin meds, anesthetic"
C-section
-2 types of incision- classic(vertical, from umbillicus to pubis, and Eow-segment incision( horiBontally, most common, also
called KbikiniL, cut thru non-active part of uterus, it is less likely to rupture in later births, therefor mom can delivder
vaginally"
2etractors then spread apart incision, oxytocin given"
AAA 1rs" ' has Hust undergone a '-section, and she and her baby have Hust entered the recovery room" 8he nurses initial
action is to inspect her dressing and lochia #not newborn assessment, as it would have already been done$
Com#ications o$ mother %ost-dei)er'
-%ost #art"m hemorrha&e: *our main causes(
1$ uterine atony( if uterus suddenly relaxes, there will be sudden gush of blood, weigh pads, palpate fundus freIuently, check
signs of shock, immediately massage fundus, infuse oxytocin,
2$ Eacerations( 1
st
to 4
th
degree
)$ 2etained placental fragments( keeps uterus from fully contracting
4$ Disseminated intravascular coagulation( deficiency in clotting due to vascular inHury
-#erinea hematoma( collection of blood in &' tissue of perineum, occurs with spontaneous births or perineal varicosities
%"er#era in$ection: increased risk with ruptured membrane over 24 hrs prior to birth, placental fragments, postpartal
hemorrhage, anemia, prolonger labor, internal fetal heart monitoring"
'ommon infections are, strep :, - 'oli, &taphylococcyl"
>ipe front to back, .ive full course of antibiotics" 1ay have difficient breastmilk"
Edometritis: infection of lining of uterus,
#eritonitis: usually extension of peritoneal cavity, maHor cause of death of mothers" &preads thru lymphatic system"
<ssess for rigid abdomen, fever, rapid pulse, vomiting" 9ften accompanies by paralytic ileus #needs ?. tube$, 3; fluids
throm-o#he-itis: inflammation of the lining of blood vessel with formation of clots" ,sually extension of endometrial
infection" 'aused by increased fibrogen levels, dialation of lower extremity viens due to pressure of fetal head, inactivity"
'an have D;8 or &;D #superficial vien disease" 3ncreased incidence with obesity, varicose viens, x of clots, women
over )!" >ear stockings"
*emoral thrombophlebitis( femoral, saphenous or popliteal viens involved" Decreases lower circulation" Positive homan/s
sign
Mastitis: organism usually enters through cracked nipples" :reasts unilateral, red, swollen" .ive antibiotic, cold
compress, support bra,
8rinar' #ro-ems: 2etention can be from bladder edema from pressure of birth, associated with use of anesthesia and
forceps" <lways measure voiding after birth"
-a-' -"es: 4!% of all births, 1-1! days after birth" Due to anticlimax, change in hormones
#ost-#art"m de#ression: 1!% of births" 1-12 months after birth"
%ost#arta #s'chosis: 1-2%"
Care o$ 6e+-orn
BATHI6A
8he room should be warm to prevent chilling" :athwater should be around @F degrees or warm to the elbow or wrist" 3f
soap is used, it should be mild and without a hexachlorophone base" :athing should be done before feeding to prevent
vomiting and possible aspiration" &upplies needed are( basin of water, mild soap, washcloth and towel, clean diaper" ?ever
leave baby unattended" :ath from cleanest to dirtiest" >ipe eyes with clear water from the inner canthus outward using a
clean portion of the washcloth for each eye to prevent spread of infection" >ash face with clear water to avoid irritation"
>ash hair daily with the bath( soap hair in crib with baby lying flat" 8hen hold baby in one arm over basin like a football,
rinse hair thoroughly and dry well to prevent chill" -ach area of baby should be rinsed well and dried" >ash area around
cord taking care not to soak the cord" < wet cord remains in place longer than a dry one and allows for bacteria growth"
>ash penis gently, and do not force the foreskin back or constriction may result" >ash the vulva in females from front to
back to prevent contamination" <void baby powders as they can cause respiratory irritation" 3f babyMs skin is dry add oil to
the bath water"
CORD CARE
>ithin a few minutes after the cord is cut, assess cord for bleeding" -'ord 'are( as to have one vein and two arteries" 1ake
sure clamp is secure" :lack by 2
nd
-)
rd
day" :reaks off after +-1!
th
day" &hould have no smell, bleeding" <pply antibiotic to
reduce infection" 'ord usually falls off around the 4-1!
th
day of life" ,ntil then the baby should be sponged bathed rather
then submerged in a tub" :e certain that the diaper is folded below the level of the cord so when the diaper becomes wet the
cord does not" Neep the cord as dry as possible until it falls off" 8he use of creams or lotions should be avoided because
they slow the drying process and invite infection" Oou can use rubbing alcohol 1-2 times daily to hasten dryness" <fter the
cord falls off a small pink granulating area about PL may remain" 8his should be left clean and dry until it heals"
MAI6 %RI6CI%LAS OF BREAST FEEDI6A
--nsure mother is relaxed and is in a comfortable position #this allows for a good let-down reflex"$
-3tMs important that the baby opens their mouths wide enough so they can grasp the nipple and areola" 8his gives them an
effective sucking action and helps to empty the collecting ducts completely" 3t also prevents the nipples from becoming
cracked and sore" 8he use of the rooting reflex is effective in encouraging the baby to grasp the nipple"
-<dvise mother to feed baby on one breast for about 1! min" and then switch to the other side increasing this time with
subseIuent feedings"
-baby should be placed first at the breast at which they fed last in the previous feeding, this ensures that each breast is
completely emptied"
-3nstruct mother on how to break suction to remove infant-have her insert her finger in the corner of the babyMs mouth or pull
down on the chin"
-Neep baby awake to ensure they are getting enough nutrition by tickling their feet or rubbing their arms7chest" 8his also
helps to produce more milk because it is produced by demand and prevent mastitis"
-:urp baby between breast changes and after the feeding"
- *eed baby when hungry, and count Q of wet diapers #+-F7day$
6e+-orn Assessment
-neonatal period is the first 2F days
-<P.<2( at 1 and 0 minutes after birth, heart rate, color, respiratory effort, muscle tone, reflex irritability are rated !, 1, or 2
and then rated out of 1!" ,nder 4 is dangerous, 4-1! is good"
-eart 2ate( starts are 1F! then lowers and stabiliBes at 12!-14!, often irregular
-blood pressure starts at F!74+, then rises to 1!!70!
-2espirations( )!-+!, short periods of apnea normal, as is crying
->eight( 2"0-)"4 kg, #)0!!g$ losses 0-1!% after birth, then should gain +-F oB per week"
-length( 4+-04 cm
-head circumference( )4-)0 cm
-chest circumference is 2 cm less the head
-temperature( )4"2 then lowers to )4"!" 'an lower due to loss of heat from convection, radiation, conduction, and evaporation
" 8hey have little insulation and don/t shiver to produce heat" 8hey have brown fat, not &' fat"
needs to pass menonium # mucous, vernix, lanugo, hormones, carbs$ by 24-4F hours" 8hen passes transitional stool, then
)-4 normal stools, " ?ewborn under lights for Haundice have bright geen stools"
;oids 12-24 hours after birth, about 10 mls"
Breast$eedin&/ n"trition:
-baby should sleep between feedings
-shouldn/t lose more than 1!% of birth weight
-;oids +-F times a day, and 2-) bm/s a day
-,sually feeds I2-4 hours" <nd will usually eventually establish a schedule"
mom produces colostrum for the first )-4 days" igh in protein, low in fat and sugar, easy to digest"
8ransitional breast milk on the 2
nd
-4
th
day, and true breast milk by day 1!"
- Practicing breast massage helps bring milk forward, ?9 soap, 9pen infants mouth >ide, place infant on breast on which
they last fed to make sure it fully empties as this leads to further milk production, wash hands first, brush baby/s cheek, place
warm packs on breasts,
- D9?/8 offer bottles until after + weeks"
- if child is under three months, and is constipated, teach mom to drink one tbsp of boiled water between feedings"
3ntroduce pureed foods one at a time, usually at 4-4 day intervals" &tart with cereals and pureed fruits
Ad)anta&es o$ -reast$eedin&: prevents breast '<, release of oxytocin aids in uterine involution, contains
immunoglobulin <, other antibacterial proteins, >:'/s , high in lactose #easily digested sugar$, amino acids, linolic acid,
better formed dental arch"
Contraindications of breastfeeding( infant that cannot digest lactose, herpes lesions on nipples, , mother on nutrient-
restricted diet, mother on meds that transfer in milk, breast '<, maternal exposure to radioactive compounds, ep :,
3;"
Re$e.es:
Blimpness or lack of muscular response can be from narcosis, shock, or cerebral inHury" 9ccasional twitching or flailing
d7t immaturity of ?&"
BinC:use sudden light
rootin&:head turns when cheek or corner of mouth is brushed
s"cCin&:suckling motion when mouth touched
s+ao+in&: same as adult
e.tr"sion: will extrude any substance placed on anterior tongue, disappears at four months
#amar &ras#: grasp obHect placed on palm
#antar &ras#: toes grasp at obHect placed on sole of foot
ste#-in-#ace: dissapears at ) months
#acin&: if legs touch edge of table, they will kick and try to step up
tonic necC: head turns to one side when lying down" <rm and leg on side which head is turned extend, and opposite arm
and leg contract
moro:startling newborn with loud noise, or holding on their back and allowing head to drop back" <rms should abduct
and extend, fingers go in /c/ shape, legs pull up to chest"
Ba-insCi: foot goes to inverted H, and toes fan out"
Ma&net: if pressure is applied to sole, while lying supine, they pull their foot back
crossed e.tension: if one sloe if irritated, the other leg pulls up and away"
tr"nC inc"r)ation: when lying prone, and a finger touches paravertabral area, they will flex trunk and swing pelvis
towards the touch
anda": newborn held prone on one arm, they should have some muscle tone, but not be able to hold up head
dee# tendon: patellar reflex""
6e+-orn Com#ications
-H'#er-iir"-inemia: 9ccurs in the 2
nd
-)
rd
day in about fifty percent on new baby/s as a result of the 2:' breakdown,
leads to Haundice" >atch newborns with lots of bruising from birth, may lead to hemorrhage" 8x is phototherapy or exchange
transfusion"
- emorrhagic disease( deficiency in ;itamin N" <ll babies get ;it N at birth"
-Anemia: due to( 1$ excessive blood loss when cord was cut 2$ inadeIuate blood flow from cord )$ fetal-maternal
transfusion 4$ mom/s poor nutrition 0$ blood incomparability
-M"co"s' Ba-': ineffective airway clearance"
-Res#irator' Distress S'ndrome: common in preterm infants due to lack of surfactant in the alveoli" 8x is artificial
surfactant by -8 tube and ventilator"
-Sma &estationa a&e: -irth +ei&ht below the 1!
th
percentile" ave difficulty maintaining body warmth d7t low birth
stores" 1ay develop hypoglycemia"
-%reterm In$ant: born before )4 weeks" ave respiratory, problems, anemia, Haundice, persistent patent ductus arteriosis,
intercranial hemorrhage" Eow birth weight is anywhere from 0!!-20!! g"
-%ostterm in$ant: past 42 weeks" Problems with meconium aspirations, hypoglucemia, respirations, temp regulation"
-Transient tach'#nea: is temporary condition caused by slow absorption of lung fluid"
-meconi"m as#iration s'ndrome: when infant inhales meconium-stained amniotic fliud during birth" Eeads to airway
spasm or pneumonia" 1ay need suctioning and 92, or antibiotic"
%EDIATRICS/FAMILY CE6TRED CARE
Factor in$"encin& &ro+th and de)eo#ment
1$ Aenetics: .ender, 2ace, ?ationality,ealth, 3ntelligence
2$ En)ironment: socioeconomic level, parent-child relationship, ordinal position in family, health, nutrition
)$ Tem#erament: temperament is the usual reaction pattern of an individual, or their characteristic manner of thinking,
behaving, or reacting to stimuli in the environment" 3t is an inborn characteristic
FRE8D
Psychosexual Stage
ERIDSO6
e!elopmental "ask
In$ant Ora Sta&e( child uses mouth and
tongue to explore the world
8o form a sense of tr"st )ers"s mistr"st" 'hild learns o love and be
loved
Todder Ana Sta&e( Eearns to control
urination and :1/s
8o form a sense of a"tonom' )ers"s shame" 'hild learns to be
independent
FRE8D
Psychosexual Stage
ERIDSO6
e!elopmental "ask
%reschooer %haic Sta&e( Eearns sexual
identity thru awareness of genital
area
8o form a sense of initiati)e )ers"s &"it" 'hild learns to do things
#basic problem solving$ and that doing things is desirable
Schoo-a&e
chid
Latent Sta&e( Personality
development appears non-
active7dormant
8o form a sense of ind"str' )ers"s in$eriorit'" 'hild learns how to
do things well
Adoescent Aenita Sta&e: Developes sexual
maturity and learns to establish
sexual satisfaction with partner"
8o form a sense of identit' )ers"s roe con$"sion" <dolescents learn
who they are and what kind of person they will be by adHusting to a
new body image, seeking emancipation from parents, choosing a
vocation, and determining a value system"
Yo"n& Ad"t <chieving a sense of intimac' )ers"s isoation" 1aking friendships
and relationships"
Midde A&e -stablish a sense of &enerati)it' )ers"s sta&nantion" -xtend
concern from themselves to families7community7world"
B the Q1 health risk for adolescence is unintentional inHuries
A2 priorities of 3; therapy in children( secure tubing, monitor 3 C 9/s, right 3; solution, verify rate, monitor insertion site,
family invovlment
-to maintain the site( use transparent drsg, cover the site, anchor tubing, observe for inflammation, infiltration"
9bserve freIuently
non)er-a comm"nication strata&ies to "se +ith Cids:
position, #turn towards her, at same height$
posture, #open, relaxed,$
facial expression, #smiling,$
movements, #nodding, mirroring$
alternate communication stratagies #play, pictures, puppests$
pitch,volume, rate, emphasis$
%a'
initiated by parent
important throughout childood
promotes physical development
EriCson: stresses importance of culture and society" 1ain tenets is that one/s social view of themselve is more influential
than than instinctual drives"
Stage o# e!elopment $ge %xample
Sensorimotor &'() months 2 mo* 6eonata re$e.: behavior only reflexive
2-5 mo* %rimar' circ"ar reaction: hand-eye-mouth coordination
5-> mo* Secondar' circ"ar reaction: learns to initiate, recogniBe, and repeat
pleasurable things
>-23 mo* Coordination o$ secondar' reactions: plans activities to attain
specific goals" -xperiences separation anxiety
23-2> mo* tertiar' circ"ar reaction: discovers new properties of obHects" as
space7time perception and permanence"
2>-35* in)ention o$ ne+ means thr" menta com-inations: ,ses memory to
imitate" 'an solve basic problems
%reo#erationa Tho"&ht ('* +ears -8hought becomes symbolic
-'omprehends abstract, but thinking is literal and concrete"
--gocentric
-&tatic thinking
-'oncept of time is now
Concrete O#erationa
Tho"&ht
*'&( +ears - systemic reasoning
-uses memory
-'lassification
-<ware of reversibility
-understands conservation
Forma O#erationa
Tho"&ht
&( +ears - can solve hypothetical problems with scientific reasoning,
-understands past,present, future
%rinci#es o$ Aro+th and De)eo#ment
1$ .rowth and development and continuous processes from conception until death"
2$ . C D proceed in an orderly seIuence
)$ Different children pass through the predictable stages at different rates
4$ <ll body systems do not develop at the same rated
0$ Development is cephalocaudal #head to toe$
+$ Development proceeds from proximal to distal body parts
4$ Development proceeds from gross to refines skills
F$ 8here is an optimum time for initiation of experiences or learning
@$ ?eonatal reflexes must be lost before development can proceed"
1!$ < great deal of skill and behavior is learned by practice"
De' 6"rsin& #oints $or carin& $or a chid in the hos#ita:
1$ Don/t tell of a hospitaliBation too far in advance" 8ell them as many days prior to a procedure as their age in years, if
under 4"
2$ :ooks about hospitaliBation are helpful"
)$ Provide continuity of care" #primary nurse$
4$ Provide opportunities for parents to do care
0$ 1aintain bed as safe area
+$ elp child to maintain control
4$ &et limits of behavior"
Medications-
1) Know child currant weight and height, as well as developmental stage so the route is appropriate.
2) Know their past experiences taking meds
3) Drugs are metabolized aster in children, thereor must be given more re!uentl"
#) $iver isn%t ull" developed in newborns, thereor distribution and metabolism is aected.
&) Kidne"snot mature intil 12 months, so excretion is limited
') (dverse reactions are exaggerated d)t immature liver and kidne"%s
*) Doses based on bod" surace area usuall".
+) (lwa"s double check dose in book
- three early manifestation of E intracrania #ress"re in chidren:
1" headache 2" ?ausea )" vomiting 4"change in E9' 0"sieBure +"irritability 4" double7blurred vision
- 4 si&ns o$ -eedin&: 1" melena( bloody stool 2" petechiae( Pinpoint red spots on the skin)" -cchymosis( skin
discoloration caused by the escape of blood in the tissues from ruptured blood vessels
- 2eferrals to parents of children who have died( social worker, spiritual edvisor, bereavement program, local support
groups
Common Chromosoma disorders:
-Down/s #trisomy 21$, 1 in F!! births, most common, esp" women over )0, or men over 00, eyelids have extra fold, iris has
white flecks, eyes turned down, small oral cavity, tongue protruding, flat back of head, extra fat at base of neck, low-set ears,
poor muscle tone, short fingers, simian line in palm,
-Nlinefelter &yndrome #males with RRO$, female characteristics"
Asthma
- defined as K a chronic inflammatory disorder of the airwaysL
- affects S1! T 2!% school-age children
- usually disappears by late adolescence
- marked by re-current attacks of dyspnea, with wheeBing d7t spasmodic constriction of the bronchi
- attacks vary from occasional periods of wheeBing C slight dyspnea to severe attacks that almost cause suffocation
- attacks which last for several days is called &8<8,& <&81<83',& this is a medical emergencyAAAAAAA
can be fatalG
'<,&-&(
- allergy to antigensU pollen, dust, smoke, automobile exhaust C animal dander
- can be secondary to chronic or recurrent infections of bronchi, sinuses, or tonsils C adenoids #hypersensitivity to
bacteria or viruses causing infection$
- family x # different types of allergies$
&7&(
- dyspnea C wheeBing type respirations
- chest tightness, tachycardia, tachypnea, anxiety, cyanosis, cough
- sitting positions C leaning forward to use all accessory muscles of respiration
- skin pale C moist with perspiration, in severe attack cyanosis of lips C nail beds
- early in attack cough is dry progresses becomes thick, productive, tenacious, mucoid sputum
- <rterial blood gases will reveal( respiratory acidosis, decreased p, increased '92, decreased 92
8R(
- supply 92
- place in high fowlers
- remain with client
- establigh 3;
- encourage slow, deep breathing
- stay calm
- avoid triggers #extrinsic factors, pollen etc"$, stress
- no cure for asthma
- bronchodilators
- expectorants may also be prescribed
Pt" '<2-(
- encourage deep breathing C fluids
- place in high fowlers,
- stay calm during attack
- relaxation techniIues #explore$
- lots of reassurance when dealing with younger children with appropriate explanations
Deh'dration in -a-ies and sma chidren
:abies and small children have an increased risk of dehydration because(
< large proportion of their bodies consists of water"
'hildren have a high metabolic rate, so their bodies use more water"
< child/s kidneys are not as efficient and do not conserve water as well as an adult/s"
8hey have an immature immune system, which increases the risk of illnesses that cause vomiting and
diarrhea"
'hildren often will not drink or eat when they are not feeling well"
8hey depend on their caregivers to provide them with food and fluids"
>atch babies, small children, and older adults closely for the early signs of dehydration any time they have illnesses that
cause high fever, vomiting, or diarrhea" 8he early symptoms of dehydration are(
< dry mouth and sticky saliva"
2educed urine output with dark yellow urine"
AEab tests ordered( ':' , lytes, kidney function tst, urine spec" gravity, urine osmolality, stools
Anore.ia
- refusal to maintain minimally normal body wt" because of disturbance inn perception of siBe of appearance of body
- can cause delayed psychosexual development
- individuals may look younger than age d7t starved appearance
- dehydration C acidosis can occur from starvation
'<2<'8-23V-D :O(
- :13 under 14"0 or less than F0% expected body wt"
- 3ntense fear of gaining wt" or becoming fat despite being grossly under wt"
- &everely distorted body image
- 2efusal to acknowledge seriousness of wt" loss
- <menorrhea #in girls$
8R(
- behavior modification( earning privileges for acceptable behavior and losing privileges
- establish trust C effective communication
- medications7anti depressants
- identifying of emotional triggers
- self monitoring #awareness training$
- education about normal nutritional needs
C'stic $i-rosis
-hereditary, chronic disease characteriBed by abnormal secretions of the exocrine glands"
-<dults with '* are barrel-chested, skinny, malnourished clubbed fingers, and receive oral pancreatic enBymes and vitamins"
-'urrent 8x is hospitaliBation with thorough pulmonary hygiene, 3; antibiotics, and antifungals, as well as postural
drainage using a range of positions to drain all segments of the lungs, and administration of pancreatic enBymes in
morning and bedtime" 1ust encourage coughing
Le"Cemia
E-,N-13< #<',8- EO1P9'O83' E-,N-13< #<EE$ $
- the distorted C uncontrolled proliferation of white blood cells #lymphocytes$
- most common '< in children
- malignant cell involved is lymphoblast #an immature lymphocyte$
- with rapid proliferation of lymphocytes, production of 2:'Ms C platelets falls, C invasion of body organs by the
increased >:' element begins
- highest incidence of <EE in kids btw" ages 2 C + and is slightly higher in boys than girls
- cause is unknown
&7&(
- pallor, low grade fever and lethargy
- may have P-8-'3< pinpoint, macular, purplish-red spots caused by intradermal or submucous hemorrhage
- bleeding from oral mucous membranes may occur
- bruise easily
- see page 1+4+ in Pilliteri for more detail C info"
8R(
- @0% of children will have first remission
- leukemia is classified to define subgroups of cells C to predict the usual response to treatment
- chemotherapeutic agents
- bone marrow transplant after a remission is achieved by chemo
BB monitor for melena, petechia, and ecchymosis, as they are signs of bleeding
AA if neutrophils or temp rise too high, the pt" &hould be put in reverse isolation
B"rns
-burns to hands and feet are increased risk fro secondary infection""""give tetanus or booster"
-3n adults, the Krule of nineL estimates extent of burn( each arm and leg are @%, head and neck is @%, 7 8his does ?98 apply
to children, as their body surfaces are different"
-Depth of burn( Partial-thickness burns are 1
st
and 2
nd
degree burns" *irst degree burns are top layer of skin #superficial
epidermis$, second degree are the entire epidermis"
-< third degree burn is a full-thickness burn" 3t involves both layers of skin, fat, muscle, bone etc" 8hey are not painful as
nerves, sweat glands, and hair is burned"
Possible complications( Pain, deficient fluid volume r7t fluid shifts, ineffective tissue perfusion, impaired urinary
elimination, imbalanced nutrition, infection
three methods of promoting emotional support in children with disturbed body image( peer contact, discuss with family
and child, aid to cover burn, referral for councelling
De#ression
- incidence 1 T )% before puberty C ) T +% in adolescents
&7&(
- loss of interest or pleasure
- significant wt" loss
- depressed mood
- insomnia
- psychomotor agitation
- diminished concentration
- feelings of worthlessness or excessive or inappropriate guilt
- recurrent thoughts of death C suicide ideation
- exists for 2 weeks or more
8R(
- counseling7therapy
- medication7anti depressants
- family support
a-"se
physical signs of sexual abuse in children(
genital pain7iritation, inHury,
undrclothing torn, blood etc
discharge
&8D/s
difficulty walking7sitting
problems with urination
presence of spermicidepregnancy
if abuse if suspected, nurse mustcontact provincial child protection agency #social services, child welfare, police$
attention/h'#eracti)it' disorder
-<DD is inattention, hyperactivity, or impulsiveness revealed before age 4, usually boys"
-8x is environmental, family support, and meds such as ritalin"
TO6SILLITIS/TO6SILLECTOMY8
- inflammation C infection of palatine tonsils
&7&(
- children drool swallowing is too painful
- high fever
- lethargy
- tonsillar tissue appears bright red, C so enlarged that tonsil tissue meet in the mid-line
- pus can be detected on or expelled from the crypts of the tonsils
- mouth breathing
8R(
- if cause bacterial antibiotics
- tonsillectomy7adenoidectomy depends on symptoms
- &x done when organs are ?98 infected, to prevent spread of pathogens
-
a##endicitis/ a##endectom'
-appendix is pouch on end of cecum, may be inflammed after other infection"
-pain is a late symptom of appendicitis, first is anorexia, ?C;, pain is 1
st
diffuse, and in 2ED or 17) way between umbillicus
and superior iliac crest #1c:urney/s point$
-Eook for rebound tenderness, Eeukocytosis, #increased >:'$
ce$t i#/#aate re#air
- congenital fissure, or split of the lip or the roof of the mouth #palate$
- one or the other occurs in S 1 in 1!!! births
- sometimes associated with clubfoot or other anatomic defects
- no connection with mental retardation
- results from failure of the two sides of the face to unite properly at early stageof prenatal development
- defect may be minor involving only outer lip of mouth or more severe involving entire upper portion of mouth
- infants unable to suckle properly opening prevents suction, feeding must be done by other means
- food may get into nose cause difficulty in chewing C swallowing , later it will hinder speech
8R(
- &x followed by measures to improve speech
- usually treatment is initiated S 1F months
Pt" '<2-(
- main concern is adeIuate nutrition pre-op C post-op
- prevention of resp" infections
- freIuent mouth care
- lots of reassurance to encourage self-esteem
- speech training also encouraged
Meases
incubation( 1!-12 days
communicability( 0
th
day of incubation to first few days of rash
transmission( direct or indirect contact with droplets, contracting disease offers lasting immunity
different from .erman measles, which last ) days" 8hese last 4 days
-have enlarged lymph nodes, fever, malaise, rhinitis, sore throat, conHunctivitis, photophobia, cough, and Noplik/s spots
# small, irregular red spots with blue7white centre$ " 8hey appear on gums, then rach spreads around hairline, ears,
forehead, neck ect"
8x6 comfort
ChicCen %o.
-<N<( ;aricella-Boster virus
-incubation( 1!-21 days #the time between exposure to the virus, and the appearance of the first symptoms$
-communicable( 1 day before rash to + days after appearance
-8ransmission( direct7indirect contact of saliva or vesicles
1ay be re-activated later as herpes Boster
Eow-grade fever, malaise, rash,
Imm"ni/ations
2-1F months( Diphtheria, Pertussis, 8etanus, Polio, aemophilius 3nfluenBae :
A :ooster for tetnus and diptheria I1! years
12-1F months( 1easles, mumps, rubella
12-1F months( 1eningococcal ' and pneumococcal conHugate
12 months( ;aricella
2 months or middle school ( ep :
+0=( Pneumococcal polysaccharide
+ months=( influenBa I yearly
2 reasons not to proceed with vaccinations( 1" prior reaction7anaphylaxis 2" encephalopathy )" immunosippressant therapy,
&ide effects( pain at site,fever, irritability, sleepiness, loss of appitite, vommiting, redness, swelling,
&ite most perferable for immuniBations with kids under one year( lateral thigh muscle
ME6TAL HEALTH
AAADuring a psychiatric emergency a nurse should( 2educe environmental stimuli, establish rapport with client7family,
assess safety, prioritiBe needs, identify available resources
AAA determine stressful events that occur at times hallucinations occur
AAAif in unsafe situation, 1$ leave room 2$ call for assistance
AAA ?urse may need to involve police, seek court order from Hudge, arrange for psych consult, or contact mental health crisis
teams in order to get pt" 8o hospital if they refuse"
SCHIFO%HRE6IA
a mental disorder characteriBed by disordered thoughts, hallucinations and delusions" 8he client loses rational thought and7or
ability to use rational mental processes especially when client is experiencing an acute episode usually due to going off
medications"
&ymptoms are considered Positive C ?egative
Positive( behaviors that clearly display pathology
?egative( represent a change from the individualMs prior personality C leads to social isolation and anhedonia
8here are 2 main approaches to treatment( psychosocial and pharmacological #neuroleptics i"e" cloBapine C olanBapine$ C
#:enBodiaBepines i"e" diaBepam C clonaBepam$ #most common side effect( Dystonia$
&ings of an active allucination( Pt"s verbal report, appears to be listening to someone else, responding to sensory stimuli,
seems distracted, reports from others
MOOD DISORDERS
1ood disorders are most often characteriBed by feelings of depression
8he most common 1D is( MaGor de#ressi)e disorder
9thers include( dysthmia #significant sadness most days for at least 2 yrs$ C :ipolar
DE%RESSIO6
( 8he state wherein an individual experiences a profound sadnessU the intense feeling of a depressed, down mood"
-if a depressed pt comes into emerg, the two most important factors the triage nurse must assess are( suicide plan, and risk of
suicide
< depressed person loses interest in activities that were previously enHoyable, as well as a loss of appetite or weight, sleep
disturbance, fatigue, feelings of worthlessness, trouble with concentration, recurrent thoughts of death or suicide
1ost important nursing intervention( establish trusting relationship with client
'ommon meds( tricyclic C related antidepressants, &&23s, 1<9 inhibitors
AAA symptoms of maHor depressive disorder( depressed for over 2 weeks, anhedonia, social withdrawal,
appetite changes, change in sleep patterns, decreased libido, impaired cognitive function
recurrent thoughts of death, feelings of worthlessness
AAA three risk factors for suicide( verbaliBed intent to commit suicide, having a plan for committing suicide, preoccupation
with death7dying, current depression, available means, lack of social support, drug7alcohol use, saying good-bye, gender
#male$, adolescent or over +!, life stressors, previous attampts
BI%OLAR DISORDER
( 'haracteriBed by episodes of excitement and racing thoughts, often, but not always alternating with episodes of depression"
.oal of treatment( to get client to a place where they are more Keven keelL
%ERSO6ALITY DISORDERS
( <n enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individuals
culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress
or impairment"
PD is usually a result of a chaotic and violent family life
'ommon types of PD(
:orderline PD T patterns of unstable personal relationships and self-image, efforts to avoid being abandoned and impulsive
actions
?arcissistic PD T self-centeredness C and inflated self esteem, overestimation of abilities, feeling superior to others and
demand admiration
<ntisocial PD T violent, impulsive, dishonest, careless C irresponsible
8reatments( psychotherapy C cognitive-behavioral therapy
?urses must recogniBe(
- these disorders in clients
- know the difficulty in establishing a nurse-client relationship
- disagreements among team members regarding client
- personal reluctance to care for client
- difficulty in reaching treatment goals
#these may be warning signs a PD exists$
%HOBIAS
( < persistent fear of a specific obHect or situation
8hey are categoriBed as(
&ocial Phobia #aka( social anxiety disorder$( severe anxiety when under social stress
&pecific Phobia( fear of things #i"e" planes, high places, animals, seeing blood$
OBSESSI(E COM%8LSI(E DISORDER
9bsessions( are recurrent thoughts, images or impulses that are experienced as intrusive and inappropriate and that cause
marked anxiety or distress
'ommon obsessions T fear of self-contamination, fear of forgetting to do something
'ompulsions( are repetitive behaviors with the goal to prevent or reduce anxiety or distress
ADDICTIO6
.oals of nursing care(
- prevent alcohol withdrawal delirium through administration of drugs
- correct fluid C electrolyte imbalances
- assess pt for associated medical conditions #i"e" liver damage, pancreatitis, altered blood glucose levels$
8reatment( drug detoxification followed by counseling, group support and medication
3n overdoses, anticipate( respiratory arrest, heart attack, cardiac arrhythmia, sieBure
%A6IC DISORDER 0an an.iet' disorder1
( Discrete episodes of intense anxiety that begin abruptly and reach a peak within about 1! minutes
&ymptoms( palpitations, sweating, trembling, &9:, sensation of choking, chest pain, nausea, diBBiness, fear of loosing
control, fear of dying, sense of altered reality
DEME6TIA
( a broad diagnosis that includes multiple physical disorders characteriBed by alterations in memory, abstract thinking,
Hudgment, and perception" 3t often results in a progressive decline in intellectual functioning and decreased activity to
perform daily activities" Poor Hudgment and insight
.radual onset over months or years"
?ursing 'are( maximiBe Iuality of life
9utcomes should be determined by the extent to which the impairment may be arrested or reversed
'haracteristics( an impairment of memory and at least one of the following T aphasia #difficulty recalling words$, apraxia,
agnosia or a disturbance must be significant enough to cause a disturbance in everyday functioning"
ALFHEMIERHS
( a progressive disorder characteriBed by stages of increasing impairment and dependency
<pproximately +!% of dementias is a result of <lBheimerMs
-arly signs of the disease #although memory impairment is the key diagnostic criteria$ are often of the behavioral type, i"e"
suspiciousness, paranoia, irritability, aggression or angry outbursts, hoarding, withdrawal
S8ICIDE
Duestions to ask(
- Do they have a plan5
- <re they able to carry it out5
- <re they rational5
Pay attention to(
- (er-a C"es
- Beha)iora C"es( previous attempts, buying a gun, stockpiling pills, giving away possessions, loss of interest,
making7changing a will, funeral plans, suspicious behavior
- Sit"ationa C"es( death of spouse7child7friend, death of pet, maHor move, diagnosis of terminal illness, retirement,
flare-up with friend7family member
?ursing 'are(
- encourage hospitaliBation
- restrict access
- establish a Ksuicide contractL or agreement
- have one-on one contact at all times
- decrease social isolation
- decrease psychological symptoms
ECT 0Eectro Con)"si)e Thera#'1
( < procedure in which clients are treated with pulses of electrical energy sufficient to cause a brief convulsion or seiBure"
8he passage of an electrical stimulus to the brain to produce a seiBure"
Particularly helpful in the elderly
3tMs carried out under anesthesia
1ost common side effect( temporary or permanent memory loss
-'8 is used primarily to treat maHor depressive episodes where other treatments have failed
?ursing 'are(
- 'onsent signed
- ?P9 midnight
- Post-op( monitor for resp distress, assess ;&, observe level of confusion, encourage rest
%atho/ Common Diseases 7 Inesses
Rhe"matoid arthritis:
for comfort, apply splints in dorsiflexion, ,se miost, warm compresses for 2! mins, and have assistive devices installed
ave family help reform passive 291/s in active 291/s are painful
Dia-etes Meit"s
8here are three types of diabetes( t'#e 2* t'#e 3* and &estationa dia-etes,
T'#e 2 dia-etesW some or all of the insulin-producing cells of the pancreas are destroyed, leaving the patient with little or
no naturally produced insulin" 9nly about 0- 1! % of people with diabetes have type 1"
8ype 1 diabetes can develop at any ageU however, it usually develops in children and young adults, which is why it was
formerly called G")enie dia-etes, 3t has also been called ins"in-de#endent dia-etes meit"s 0IDDM1 because insulin
must be taken daily
"
T'#e 3 dia-etes( most common form of diabetesW the pancreas makes insulin but the cells in the body do not respond to it"
06IDDM1
Aestationa dia-etesIcertain pregnancy-related hormones make the body resistant to insulin"
Dia-etic com#ications
E'e dama&e 0retino#ath'1 X 3n this disorder, tiny blood vessels at the back of the eye are damaged by high blood
sugar"
6er)e dama&e 0ne"ro#ath'1 X igh blood sugar can damage nerves, leading to pain or numbness of the affected
body part" Damage to nerves in the feet, legs and hands #peripheral neuropathy$ is most common"
Foot #ro-ems X &ores and blisters commonly occur on the feet of people with diabetes" 3f peripheral neuropathy
causes numbness, a sore may not be noticed and it can become infected" :lood circulation can be poor, leading to
slow healing" Eeft untreated, a simple sore can lead to gangrene #the death of soft tissue due to lack of blood flow$,
and sometimes the leg or a portion of it may need to be removed surgically #amputated$"
Didne' disease 0ne#hro#ath'1 X igh blood sugar can damage the kidneys" 3f blood sugar remains high, it can
lead to kidney failure"
Heart and arter' disease 0atheroscerosisI deposits of fatty substances, cholesterol, cellular waste products,
calcium and other substances build up in the inner lining of an artery" 8his buildup is called plaIue1 X eart and
blood vessel problems can result from high blood sugar" People with type 1 diabetes are more likely to have heart
disease, strokes and problems related to poor circulation"
Dia-etic Cetoacidosis X 8his occurs when acidic substances called ketones are made by the liver as a substitute
energy fuel instead of glucose" &ymptoms include nausea and vomiting, abdominal pain, fatigue, lethargy and,
eventuallyW coma and death" #assoc" with hyperglycemia$ &ymptoms of hyperglycemia W freIuent urination, thirst,
weakness and fatigue"
H'#o&'cemia X Eow blood sugar, called hypoglycemia, can result if too much insulin is taken or not enough
carbohydrates are take in to balance the insulin" &ymptoms include weakness, diBBiness, trembling, sudden sweating,
headache, confusion, irritability, and blurry or double vision" ypoglycemia can lead to coma if it is not corrected by
eating or drinking carbohydrates" 'an be brought on by alcohol intake"
Diabetics should carry a source of concentrated glucose #glucose tabs, candy$, as well as a source of complex carbs
and a protien which would follow #cracker and cheese$ in case of hypoglycemia"
FYI: Dia-etes Insi#id"s is a rare metabolic disease that is not reated to diabetes mellitus" 3t is characteriBed by a
deficiency of the hormone )aso#ressin 0anti-di"retic hormone, ADH1* which is produced in the posterior lobe of the
pituitary gland" 8he lack of effect of this hormone on the kidney causes excretion of excessive Iuantities of very dilute #but
otherwise normal$ urine" -xcessive thirst and urination are the maHor symptoms of this disorder"?ormal :&( 4-4
-&igns7symptoms of hypoglycemia
-&igns7symptoms of hyperglycemia
-ow to respond (yper-
ypo-
-3nsulin <dministration
-&hort acting insulin(
Eong acting 3nsulin(
%er$orated Coon
symptoms of perforated colon( acute increase on abd" pain, rigid abdomen, absent #decreased bowel sounds
9ne life-threatening complication on perforated colon( &hock #hypovolemic or septic$, peritonitis
H'#oth'roidism
ypothyroidism develops when the thyroid gland does not produce enough thyroid hormone, which regulates the way the
body uses energy" >hen levels of thyroid hormones are abnormally low, the body -"rns ener&' more so+'* and )ita
$"nctions* s"ch as heart-eat and tem#erat"re re&"ation* so+ do+n, 8he incidence of hypothyroidism tends to increase
with age, with older women at highest risk"
8he most common cause of hypothyroidism in 'anada is ashimoto/s thyroiditisWdevelops when the immune system
produces antibodies that destroy thyroid tissue and thus reduce the thyroid/s ability to produce thyroid hormone" 9ther causes
of hypothyroidism include the surgical removal of the thyroid gland, radioactive iodine therapy, and as a phase of thyroiditis
after childbirth"
CHF
'ontrary to its name, congestive heart failure does not mean the heart has failed completely" 3t means the heart no longer is
able to meet the body/s need for blood because it is pumping inefficiently" 8his inefficient pumping causes a backup of blood
in the veins leading to the heart" 8he body tries to compensate for the reduced pumping ability of your heart by(
2etaining salt and water by the kidneys to increase the amount of blood in your bloodstream" 8his causes the body/s
tissues to swell" 8he swelling #edema$ most commonly affects the legs, but it also can occur in the lungs, causing
breathing difficulty, and in other tissues and organs"
3ncreasing the heart rate
3ncreasing the siBe of your heartWknown as KcardiomegalyL"
'ongestive heart failure often is the end stage of another form of heart disease" 3ts many causes include( coronary artery
disease, hypertension, heart valve disorders #including rheumatic heart disease$, congenital heart disorders, cardiomyopathy
#disease of the heart muscle$, heart attack, cardiac arrhythmias #problems with the heart rate and7or rhythm$, and toxic
exposures, including excessive intake of alcohol" yperthyroidism, diabetes and chronic lung disease also increase the risk of
congestive heart failure"
Treatment
8he first treatment of congestive heart failure focuses on controlling the most severe #acute$ symptoms" :ed rest is
prescribed to elevate the legs and discourage fluid accumulation in the feet and ankles
Diuretics are administered to remove excess body fluid by increasing urine output"
Digoxin #Eanoxin$ to strengthen the heart/s contractions
<'- inhibitors or angiotensin receptor blockers to expand blood vessels, decrease the resistance to blood flow, and
help to prevent water retention
:eta-blockers to improve blood flow
<nticoagulants also are prescribed to prevent blood clots, particularly if the patient reIuires a long period of bed
rest"
MI
< heart attack occurs when one of the heart/s coronary arteries is blocked suddenly, usually by a tiny blood clot
#throm-"s$" 8he blood clot typically forms inside a coronary artery that already has been narrowed by atherosclerosis, a
condition in which fatty deposits #plaIues$ build up along the inside walls of blood vessels"
AAA'or pulmonale( 'or pulmonale is failure of the right side of the heart caused by prolonged high blood pressure in the
pulmonary artery and right ventricle of the heart"
&ymptoms
8he most common symptom of a heart attack is severe angina, or chest pain, also described as discomfort, pressure,
sIueeBing, or heaviness" 1any people also have at least one other symptom, such as(
Pain or discomfort that radiates to the back, Haw, throat, or arm"
Discomfort in the upper abdomen, often mistaken for heartburn"
&weating, nausea, and vomiting"
Difficult breathing, palpitations, diBBiness, and fainting"
>eakness, numbness, and anxiety"
>omen, older adults, and people with diabetes are less likely to have chest pain during a heart attack and more likely to have
other symptoms"
Diagnosis
-'. can detect signs of insufficient blood flow, heart muscle damage, abnormal heartbeats, and other heart
problems"
'ardiac enByme studies measure the levels the enBymes troponin ,creatine phosphokinase #'PN, 'N$, and lactate
dehydrogenase #lactic acid dehydrogenase or ED$ in the blood"
8reatment
92
pain medication #usually morphine$ for chest pain
beta-blockers to reduce the heart/s demand for oxygen
nitroglycerin to temporarily increase blood flow to the heartWif blood pressure is not too low
<'- #angiotensin-converting enByme$ inhibitors, which help the heart work more efficiently, primarily by
lowering blood pressure
<spirin
1ost heart attack patients also are given a prescription for a cholesterol-lowering medication"
An&ina
<ngina, also called angina pectoris, is discomfort or pain in the chest that happens when not enough oxygen-rich blood
reaches the muscle cells of the heart" <ngina is not a disease, but a symptom of a more serious condition, usually
coronar' arter' disease* an illness in which the vessels that supply blood to the heart become narrow or blocked"
'oronary artery disease is usually caused by atheroscerosis* a condition in which fatty deposits #called plaIue$ build up
along the inside walls of blood vessels" <lthough angina most commonly affects males who are middle-aged or older, it
can occur in both sexes and in all age groups"
Sta-e an&ina X 'hest pain follows a specific pattern, occurring when someone engages in hard physical activity
or experiences extreme emotion" 9ther situations that bring on angina include smoking a cigarette or cigar, cold
weather, a large meal and straining in the bathroom" 8he pain usually goes away when the pattern or trigger ends"
8nsta-e an&ina X &ymptoms are less predictable and should prompt an immediate call to a health professional"
8his chest pain occurs at rest, during sleep or very often with minimal exertion" 8he discomfort may last and be
intense"
8reatment
Li$est'e chan&es X 'hanges include weight loss for obese patients, therapy to Iuit smoking, medications to lower
high cholesterol, a program of regular exercise to lower high blood pressure, and stress reduction techniIues #for
example, meditation and biofeedback $"
?itrates, including nitroglycerin X ?itrates are vasodilators #medications that widen blood vessels$" 8hey increase
blood flow in the coronary arteries, and make it easier for the heart to pump blood to the rest of the body"
:eta-blockers, such as atenolol and metoprolol #Eopressor, 8oprol-RE$ X 8hese medications decrease the heart/s
workload by slowing the heart rate and reducing the force of the heart/s contractions, especially during exercise"
'alcium channel blockers, such as nifedipine #<dalat, Procardia$, verapamil #'alan, 3soptin, ;erelan$, diltiaBem
#'ardiBem, 8iaBac$, amlodipine #?orvasc$ X 8hese medications may help to improve the efficiency of heart-
muscle function and may decrease the number and severity of episodes of chest pain"
<spirin X :ecause aspirin helps to prevent blood clots from forming inside narrowed coronary arteries, it can
reduce the risk of heart attacks in people who already have coronary artery disease"
'ardiac <rrest
< cardiac arrest is the cessation of normal circulation of the blood due to failure of the ventricles of the heart to contract
effectively during systole" 8he resulting lack of blood supply results in cell death from oxygen starvation" 'erebral
hypoxia, or lack of oxygen supply to the brain, causes victims to immediately lose consciousness and stop breathing"
RES%IRATORY
B -est #osition $or #t +ith chest t"-eJ semi-$o+ers* side-'in& +ith head raised
Ad)entitio"s Breath so"nds:
stridor( shrill, harsh sound- heard on inspiration in laryngeal obstructions
crackle #formally rale$( explosive, YpoppingY sounds heard more commonly during inspiration imply either accumulation
of fluid secretions or exudate within airways or inflammation and edema in the pulmonary tissue" *ineWcoarse
3nterventions( Diuretics, 8urn C position ,Deep breathing ,*orced expiration ,;ibration C percussion
wheeBes( musical or whistling sound, results form constriction or obstruction of throat, pharynx, trachea, bronchi"
<ssociated with asthma" 1ostly heard on expiration" 3nterventions( :ronchodilation, ydration , 'oughing
2honchi( bubbling sound, Eouder than rales due to larger secretions, 2esults from air bubbling past secretions in the
airways, heard throughout inspiration and expiration" 3nterventions(
o Deep breathing
o 'oughing
o ydration #encourage fluids, if no restriction$
o umidify air
o 1obiliBe
R"-: creaking, leathery sound, 'aused by rubbing of inflamed pleural surfaces against lung tissue, heard at end of
inspiration and beginning of expiration
T"-erc"osis
-transmitted via airborn transmission
-factors that contribute to the incidence of 8:(
- physical environment #crowding, prolonged contact, poor ventilation$
- psycological environment #stress, drugs$
-social environment #homelessness$
- poor nutrition
-lack of medical attention
- increased immigration
-increased drug resistance
2 interventions health nurses can do to control the spreas of 8: in people who live in the street( 1$direct observed therapy
2$ teach hygeine )$ identify facilities that provide meals 4$ evaluate side-effects of medications 0$ identify at-risk people
+$ identify other living arrangements
Deh'dration
Dehydration occurs when your body loses too much fluid" >hen you stop drinking water or lose large amounts of fluids
through diarrhea* )omitin&* s+eatin&* or stren"o"s e.ercise* your body/s cells absorb fluid from the blood and other body
tissues" >hen you are not drinking enough fluids, your muscles begin to get tired and you may have leg cramps or feel faint"
:y the time you become severely dehydrated, there is no longer enough fluid in the body to get blood to your organs" Oou
may begin to go into shock, a life-threatening condition"
A .lucose and electrolyte based fluids #4-up, gatoraid, poweraid$ are the best when gastric discomfort first occurs to avoid a
fluide7lyte imbalance"
Dehydration can occur at any age, but it is most dangerous for babies, small children, and older adults"
assess( skin turgur, wt, mucouse membranes, pulse, :P, vitals, urine concentration
Consti#ation
Ca"ses: codiene, iron, caffiene, little activity, high-fiber diet
&ymptoms( hard stools, distention, discomfort, anorexia, decreases bowel sounds, nausea, diBBy, headache, increased
flatulence, rectal pressure,
8reatment( more water, dietary fiber, activity, limit caffiene, colace, sennokot
8ake metmucil 2 hours after other pills, as it will affect the absorption of other meds"
Eectro'te Im-aance
8he serum electrolytes include(
&odium #?a=$Whelps balance fluid levels in the body and facilitates neuromuscular functioning"
Potassium #N=$W helps to regulate neuromuscular function and osmotic pressure"
'alcium #'a2=$Waffects neuromuscular performance and contributes to skeletal growth and blood coagulation"
1agnesium #1g2=$W 3nfluences muscle contractions and intracellular activity
'hloride #'3-$Whelps regulates blood pressure"
Phosphate #P94-$Wthat impacts metabolism and regulates acid-base balance and calcium levels"
:icarbonate #'9)-$W assists in the regulation of blood p levels" Bicar-onate ins"$$iciencies and ee)ations
ca"se acid--ase disorders 0i,e,* acidosis* aCaosis1,
1edications, chronic diseases, and trauma #i"e", -"rns, $ract"res etc"$ may cause the concentration of certain electrolytes in
the body to become too high #hyper-$ or too low #hypo-$" >hen this happens, an electrolyte imbalance, or disorder, results"
HY%ER6ATREMIA
&odium helps the kidneys to regulate the amount of water the body retains or excretes" 'onseIuently, individuals with
elevated serum sodium levels also suffer from a loss of fluids, or deh'dration" H'#ernatremia can be caused by inadeIuate
water intake, excessive fluid loss #i"e", dia-etes insi#id"s, kidney disease, severe burns, and prolonged vomiting or
diarrhea$, or sodium retention" &ymptoms of hypernatremia include(
thirst
irregular heartbeat #tachycardia$
irritability
fatigue
lethargy
heavy, labored breathing
muscle twitching and7or seiBures
HY%O6ATREMIA
,p to 1% of all hospitaliBed patients develop h'#onatremia, making it one of the most common electrolyte disorders"
Di"retics* certain #s'choacti)e dr"&s #i"e", fluoxetine, sertraline, haloperidol$, specific anti#s'chotics #lithium$,
)aso#ressin* chor#ro#amide* the illicit drug Yecstasy,Y and other pharmaceuticals can cause decreased sodium levels, or
hyponatremia" Eow sodium levels may also be triggered by inadeIuate dietary intake of sodium, excessive perspiration,
water intoxication, and impairment of adrenal gland or kidney function" &ymptoms of hyponatremia include(
nausea, abdominal cramping, and7or vomiting
headache
edema #swelling$
muscle weakness and7or tremor
paralysis
disorientation
slowed breathing
seiBures
coma
HY%ERDALEMIA 0remem-er* DK is the L2 cation I6SIDE ces1
H'#erCaemia may be caused by ketoacidosis #diabetic coma$, myocardial infarction #heart attacC$, severe burns, kidney
failure, $astin&, -"imia ner)osa, gastrointestinal bleeding, adrenal insufficiency, or Addison!s disease" Diuretic drugs,
cyclosporin, lithium, heparin, <'- inhibitors, -eta -ocCers, and trimethoprim can increase serum potassium levels, as can
heavy e.ercise" 8he condition may also be secondary to hypernatremia #low serum concentrations of sodium$" &ymptoms
may include(
weakness
nausea and7or abdominal pain
irregular heartbeat #arrhythmia$
diarrhea
muscle pain
HY%ODALEMIA
&evere dehydration, aldosteronism, C"shin&!s s'ndrome, kidney disease, long-term diuretic therapy, certain #eniciins,
laxative abuse, congestive heart $ai"re, and adrenal gland impairments can all cause depletion of potassium levels in the
bloodstream" &ymptoms of h'#oCaemia include(
weakness
paralysis
increased urination
irregular heartbeat #arrhythmia$
orthostatic hypotension
muscle pain
tetany
HY%ERCALCEMIA
:lood calcium levels may be elevated in cases of thyroid disorder, m"ti#e m'eoma, metastatic cancer, multiple bone
fractures, milk-alkali syndrome, and Paget/s disease" -xcessive use of calcium-containing supplements and certain over-the-
counter medications #i"e", antacids$ may also cause h'#ercacemia" &ymptoms include(
fatigue
consti#ation
depression
confusion
muscle pain
nausea and vomiting
dehydration
increased urination
irregular heartbeat #arrhythmia$
HY%OCALCEMIA
8hyroid disorders, kidney failure, severe burns, se#sis, )itamin D de$icienc', and medications such as he#arin and
&"co&an can deplete blood calcium levels" Eowered levels cause(
muscle cramps and spasms
tetany and7or convulsions
mood changes #depression, irritability$
dry skin
brittle nails
facial twitching
Chronic O-str"cti)e %"monar' Disease 0CO%D1
-refers to a group of disorders that damage the lungs and make breathing increasingly more difficult over time" :oth are
chronic #long-term$ illnesses that impair airflow in the lungs" 8he two most common forms of '9PD are(
chronic -ronchitis W the air passages in the lungs are inflamed, and the mucus-producing glands in the larger
air passages of the lungs #bronchi$ are enlarged" 8hese enlarged glands produce too much mucus, which triggers a
cough" 3n chronic bronchitis, this cough lasts for at least three months of the year for two consecutive years
em#h'sema I the tiny air sacs in the lungs, called alveoli, are destroyed" 8he lungs are unable to contract
fully and gradually lose elasticity" oles develop in the lung tissue, reducing the lungs/ ability to exchange oxygen for
carbon dioxide" <s a result, breathing may become labored and inefficient, and you may feel breathless most of the time
AA when applying 92, watch for drowsiness, decreased resps, and lethargy"
Rena Fai"re
8he kidneys lose their ability to filter enough waste products from the blood and to regulate the body/s balance of salt and
water" -ventually, the kidneys slow their production of urine, or stop producing it completely" >aste products and water
accumulate in the body" 8his can lead to a potentially life-threatening overload of fluids #such as con&esti)e heart
$ai"re $, a dangerous accumulation of waste products in the blood, and extreme changes in blood chemistry that
eventually can affect the function of the heart and brain" 8here are three types of 2*(
Ac"te rena $ai"re W the kidneys stop functioning properly because of a sudden illness, a medication or medical
condition that causes one of the following(
o < severe drop in blood pressure or an interruption in the normal blood flow to the kidneys, which can occur
during maHor surgery, severe burns with fluid loss through burned skin, massive bleeding #hemorrhage$ or a
heart attack that severely affects heart function"
o Direct damage to kidney cells or to the kidneys/ filtering units, which can be caused by an inflammation of
the kidneys called &omer"one#hritis* toxic chemicals, medications and infections"
o :locked urine flow from the kidney, which can occur because of obstructions outside the kidney, such as
kidney stones, bladder tumors or an enlarged prostate" :lockage of urine flow within the kidney also can
cause sudden kidney failure, as can occur with maHor muscle inHury"
o 3f left untreated, acute renal failure can cause congestive heart failure #because the extra fluid backs up
behind the heart into the lungs$and cardiac rhythm abnormalities
o 1easure output every hourGGGG
o should eat a low-protein, high carb, high fat diet" <ppitite is best in am, therefor a high cal breakfast is best
Chronic rena $ai"re W the functioning of the kidney gradually declines, usually over a period of years" 1ost
commonly, it is caused by illnesses such as diabetes, uncontrolled high blood pressure or chronic kidney
inflammation #glomerulonephritis or pyelonephritis$"
End-sta&e rena disease W kidney function deteriorates until the person dies" 8his is usually the end result of
longstanding chronic renal failure, but occasionally, it also follows acute renal failure" 1ay be drowsy and
confused at this point" >atch for their safety"
9liguria6 no peeing
Cere-ra (asc"ar Accident 0C(A1J StroCe
W the blood supply to a part of the brain is suddenly diminished or cut off" 8here are two maHor types of stroke(
Ischemic stroCe is the most common type of stroke" 3t is characteriBed by the presence of a blood clot that blocks
the flow of blood to one area of the brain, depriving that area of oxygen"
Throm-otic stroCe is a type of ischemic stroke, accounts for 4! percent to 0! percent of all cases of stroke" 3n
thrombotic stroke, a blood clot forms in one of the brain/s arteries, blocking blood flow to the brain" 3n most cases,
the artery was already narrowed as a result of atherosclerosis #fatty build-up$"
Em-oic stroCe is a type of ischemic stroke, accounts for 2! percent of all cases of stroke" 3n embolic stroke, a blood
clot originates in the heart or in blood vessels outside of the brain and travels to one of the brainMs arteries,
obstructing the flow of blood"
Hemorrha&ic stroCe accounts for 1! percent to 10 percent of all cases of stroke" 3n hemorrhagic stroke, bleeding in
the brain itself #intracerebral hemorrhage$ or between the brain and the skull #subarachnoid hemorrhage$ disrupts
brain function" :leeding usually occurs because of a rupture in arterial walls that are already weakened by high
blood pressure" < pool of blood compresses brain tissue in its vicinity, preventing adeIuate amounts of fresh blood
from reaching the area"
&troke is a medical emergency" :oth ischemic and hemorrhagic strokes may have devastating conseIuences" owever, of the
two types, hemorrha&ic stroCe is more iCe' to -e dead',
BBearly nursing intervention for hemiplegia6passive 291/s to affected side
AAA 2isk factors( hypertension, smoking, atherosclerosis, diabetes, obesity, sedentary lifestyle, hyperlipidemia, <"*ib, clot
disorder, birth control pills, cardiac disease, 83</s, substance abuse,
AAA 1eds appropriate for ishemic stroke( 1$ anticoagulants #heparin, coumadin$ 2$ 8hrombolytic therapy )$ antiplatlet
therapy #<&<$, 4$ Diuretics #Easix$ 0$ 'alcium 'hannel blockers +$ barbiturates 4$ anticonvulsants F$ hyperosmotics
<ccording to our ;3< orientationWthere is a 4 ho"r +indo+ in which tP< can be administered successfully to ischemic
stroke patients"
Transient Ischemic AttacC 0TIA1
W sometimes called a Ymini-stroke,Y is an episode of stroke-like symptoms that lasts less than 24 hours, usually five to 2!
minutes" 3n a 83<, circulation to a part of the brain is interrupted briefly, then restored" 8his interruption can result from a
narrowing of a brain artery because of atheroscerosis or a small floating blood clot that entered the bloodstream from
somewhere else in the body, often the heart, and temporarily blocked a brain artery"
HI(/AIDS
8he human immunodeficiency virus #3;$ weakens the body/s immune defenses by destroying 'D4-lymphocytesWperson
becomes vulnerable to many different types of infections" 8hese infections are called opportunistic because they have an
opportunity to invade the body when the immune defenses are weak" 3; infection also increases the risk of certain cancers,
illnesses of the brain #neurological$ and nerves, body wasting and death"
8he virus is spread through contact with an infected person/s body fluids, especially through blood, semen and vaginal fluids"
9nce inside the body, 3; particles invade 'D4 lymphocytes and use the cells/ own genetic material to produce billions of
new 3; particles" 8hese new particles cause the infected 'D4 cell to burst #lyse$" 8he new particles can then enter the
bloodstream and infect other cells" -ventually, the number of normal 'D4 cells drops below the threshold level needed to
defend the body against infections, and the person develops <3D&"
He# B
-&ymptoms( muscle aches, Haundice, anorexia, diarrhea
-spread thru unprotected sex, blood, body fluids
-encourage pt" 8o resume activities gradually,
- diet( hight in carbs for healing, low proteins as the liver can/t metaboliBe protein by-products
S"r&er' Com#ications:
1" ShocC
&hock is a medical emergency in which the organs and tissues of the body are not receiving an adeIuate flow of blood" 8his
deprives the organs and tissues of oxygen and allows the buildup of waste products" &hock can result in serious damage or
even death"
Ca"ses and s'm#toms
&hock is caused by three maHor categories of problems(
cardio&enic W problems associated with the heart/s functioning
h'#o)oemicI the total volume of blood available to circulate is low , and
se#tic shocC Wcaused by overwhelming infection, usually by bacteria
Cardio&enic shocC can be caused by any disease, or event, which prevents the heart muscle from pumping strongly and
consistently enough to circulate the blood normally" Heart attacC, conditions which cause inflammation of the heart muscle
#m'ocarditis$, disturbances of the electrical rhythm of the heart, any kind of mass or fluid accumulation and7or blood clot
which interferes with flow out of the heart can all significantly affect the heart/s ability to adeIuately pump a normal Iuantity
of blood"
H'#o)oemic shocC occurs when the total volume of blood in the body falls well below normal" 8his can occur when there
is excess fluid loss, as in dehydration due to severe vomiting or diarrhea, diseases which cause excess urination #diabetes
insipidus, diabetes mellitus, and kidney failure$, extensive burns, blockage in the intestine, inflammation of the pancreas
#pancreatitis$, or severe bleeding"
Se#tic shocC can occur when an untreated or inadeIuately treated infection #usually bacterial$ is allowed to progress"
:acteria often produce poisonous chemicals #toxins$ which can cause inHury throughout the body" >hen large Iuantities of
these bacteria, and their toxins, begin circulating in the bloodstream, every organ and tissue in the body is at risk of their
damaging effects" 8he most damaging conseIuences of these bacteria and toxins include poor functioning of the heart
muscleU widening of the diameter of the blood vesselsU a drop in blood pressureU activation of the blood clotting system,
causing blood clots, followed by a risk of uncontrollable bleedingU damage to the lungs, causing acute res#irator' distress
s'ndromeU liver failureU kidney failureU and coma"
3nitial symptoms of shock include(
cold, clammy hands and feetU
pale or blue-tinged skin toneU
weak, , thready, fast pulse rateU
fast rate of breathingU
low blood pressure"
Irre)ersi-e #hase o$ h'#o)oemic shocC: ra#id* shao+ -reathin&* cracCes and +hee/es
BBBB #"t on O3 and #ace in trendeen-er&
8reatment includes keeping the patient warm, with legs raised and head down to improve blood flow to the brain, putting a
needle in a vein in order to give fluids or blood transfusions, as necessaryU giving the patient extra oxygen to breathe and
medications to improve the heart/s functioningU and treating the underlying condition which led to shock"
2" Hemorrha&e
4, Dee# )ein throm-osis #D;8$
< common but difficult to detect illness that can be fatal if not treated effectively" 'an causeW #"monar' em-oism, a
potentially fatal complication where the blood clots break off and form pulmonary emboli, plugs that block the lung arteries"
Deep vein thrombosis is also called throm-o#he-itis
Deep vein thrombosis is a maHor complication in patients who have had ortho#edic s"r&er' or pelvic, abdominal, or
thoracic s"r&er'" Patients with cancer and other chronic illnesses #including congestive heart $ai"re$, as well as those who
have suffered a recent myocardial infarction, are also at high risk for developing D;8" Deep vein thrombosis can be chronic,
with recurrent episodes"
S'm#tomsW pain, redness #-rythema$ , swelling, warmth in affected areaWalso positive omanMs sign"
5, In$ection
0" Air em-oi: place ot on left side to prevent air from entering the pulmonary circulation
ETOH +ithdra+a S'm#toms
Ear' s'm#toms X 8hese usually begin within five to 1! hours after the last alcoholic drink and typically peak at 24 to
4F hours" &ymptoms may include( tremors, rapid pulse,an increase in blood pressure, rapid breathing, fever, sweating,
nausea and vomiting, anxiety, depressed mood, irritability, nightmares and insomnia"
<lcohol-withdrawal seiBures #Yrum fitsY$ X 8hese may occur six to 4F hours after the last drinkU the risk peaks at 24
hours"
Delirium tremens X Delirium tremens commonly begins two to three days after the last alcoholic drink, with peak
intensity at four to five days" &ymptoms include confusion, disorientation, changes in levels of consciousness, agitation
#being very upset$, delusions #irrational beliefs$, sleep disturbances and hallucinations" ;isual hallucinations may be
especially common, although it is not clear why"
MEDICATIO6S
A 3f a med error occurs *32&8 assess pt, then call Dr"
LASIM: 0di"retic1
3ndications( treatment of edema associated with congestive heart failure, cirrhosis of the liver, and renal disease"
9verdose &ymptoms( dehydration, electrolyte depletion C hypotension"
<dverse 2eactions( '?&-headache, restlessness
';-hypotension
.3- pancreatitis, abd pain and discomfort"
.,- polyuria
?ursing 'are( 1onitor weight, :"P C pulse"
1onitor fluid intake and output"
,,potent diuretic can lead to pro#ound diuresis -ith -ater and electrolyte depletion. Monitor #or hyokalemia.
DIAOMI6
<ction( &trengthens myocardial contractions by inhibiting sodium potassium activated adenosine triphosphatase"
3ndications( heart failure, atrial fib"
<dverse reactions( '?&-fatigue, muscle weakness
';-arrhymias
.3 Tanorexia, nausea vomiting,

?ursing 'onsiderations( ,se with extreme caution in the elderly and in those with acute 13, renal insufficiency, and other
heart conditions"
:efore administering a loading dose, obtain baseline data #heart rate, rhythm, :"P" and electrolytes$" Eoading dose is divided
over a 24 hr period"
:efore administering drug take apical pulse for 1min,
1onitor serum digoxin levels, therapeutic levels range from !"0-2ng7ml"
,,excessive slowing o the pulse -'. beats or less) ma"be signs o toxicit", monitor serum potassium levels and take action
beore h"pokalemia occurs, withhold drug and call ph"sician.
S/S o# toxicity/ anorexia0 n1!0 headache0 #atigue0 depression0 con#usion0 nightmares0 -eakness
MOR%HI6E
'?& drug, ?arcotic C 9pioid analgesics
<ka( morphine sulfate, epimorph, 1& 'ontin, 1&32
3ndications( severe pain
&7& overdose( extreme sedation, resps Z127min"
AA causes vasodilation, therefor it can be perscribed to pt"s with &9:, crackles and chest pain, and together with lasix, it will
decrease crackles and lead to == diuresis
?ursing considerations(
- keep narcotic antagonist ?<E9R9?- C resuscitation eIuip" available
- donMt crush or chew extended release tabs"
- epidural 2oute( monitor resps" closely for resp" depression #check D)!-+!min"x 24hr$
- may cause transient decrease in :P
- constipation commonly severe with maintenance dose, ensure stool softners are ordered
- monitor circulatory, respiratory, bladder C bowel functions carefully
- ?=; are common side effects
ATRO%I6E
'ardiovascular system drugs, <ntiarrhythmics
<ka( atropine sulfate
3ndications( symptomatic bradycardia, bradyarrhythmia #Hunctional or escape rhythm$, antidote for anti-cholinesterase
insecticide poisoning, preoperatively to diminish secretions C block cardiac vagal reflexes, adHunct 8x of peptic Dx, 8x of
functional .3 disorders such as 3:& #irritable bowel syndrome$
&7& overdose(
?ursing considerations(
- use cautiously in PtMs with Down syndrome may have increased sensitivity to drug
- many adverse reactions #incl" dry mouth C constipation$
- watch for tachycardia in cardiac PtMs may lead to ventricular fibrillation
- monitor fluid intake C urine output drug causes urine retention C urine hesitancy
- suggest use of sunglasses to those who experience photophobia
A6TIHY%ERTE6SI(ES
Antih'#ertensi)es Tthe K ololsL ( beta blockers and KprilsM( <'- inhibitors
- Meto#roo Rami#ri
- %ro#ranoo N"ina#ri
- <ction( [myocardial contractibility <ction( Prevents conversion of angiotensin
3W33
- [2 #<ngiotension 33 is a potent vasoconstrictor$
- ['ardiac output
- [:P
- [myocardial 92need
- <dverse 2x( bradycardia, ypotension, eart failure
I6S8LI6
0B"e namesIne+ (IHA dr"& stocCO6o)o 6ordisC Ins"in1 E$$ecti)e Pan 3@@:
T'#e Brand 6ame Onset %eaC D"ration Comments
2apid acting umalogW
6o)ora#id
>ithin
2@
minutes
5: - ?@
minute
s
4 -:
hours
2apid acting, uman
&hort acting
#regular$
umulin 2W
6o)oin
Toronto
4@
minutes
3 - 5
hours
> hours uman
9ften inHected before meals to
compensate for the sugar intake
from food
3ntermediate
acting
umulin ?W
6o)oin 6%H
2,:
hours
; - >
hours
35 hours uman
1ixtures umulin
4!7)!W
6o)oin <@/4@
4@
minutes
3-:
hours
and
;-23
hours
35 ho"rs 8he numbers refer to percentage
of 6%H #1st number$ and re&"ar
#2nd number$
<vailable in vials, pen-fill
cartridges, and prefilled syringe
Discard a )ias 4@ da's a$ter o#enin&
He#arinI anticoagulant
- prevents conversion of fibrinogen to fibrin #8herefore, prevent blood clots$
- for prevention of post-op D;8, 13, P-
- also for patency maintenance of indwelling catheters
- 2outes( 3; drip, &'
- <dverse 2x( hemorrhage, overly prolonged clotting times #P8-3?2, P88$ thrombocytopenia
- 1onitor P8-3?2 and P88
- Dosage is highl" individualized based on age, disease state, renal and hepatic unction
6ITRO
?3829 T 'ardiovascular system drug, <ntianginals
<ka( nitroglycerine, glyceryl trinitrate, ?itro-:id, ?itro-Dur, 8ransderm-?itro
3ndications( prophylaxis against chronic anginal attacks, acute angina pectoris, prophylaxis to prevent or minimiBe anginal
attacks before stressful events, 8? from &x, heart failure after 13, angina pectoris in acute situations, to produce controlled
hypotension during &x #by 3";" infusion$
&7& overdose(
?ursing considerations(
- use cautiously in PtMs with hypotension or volume depletion
- AA closely monitor ;& during infusionAAAespecially :P in PtMs with an 13 excessive hypotension may worsen the
13AAA
- wear gloves applying ointment or patch to avoid absorption of drug ?: to remove old transdermal patch before
applying new one"AAA remove patch before defibrillationmay cause electric current to arch that can damage
paddles and burn Pt"
- AA gradually decrease dose C freIuency of transdermal patch when stopping 8x"
- 1onitor :PC intensityC duration of drug response
- drug may cause headaches during start of 8x treat headaches with 8ylenol or aspirin
- advise PtMs to avoid alcohol increased hypotension
- teach Pt( sublingual dose may be repeated x) I0 min if no relief, obtain med" help immediately
LITHI8M #anti-manic7mood stabiliBer$
:lood levels only a little above the therapeutic level range may lead to serious adverse effects" Thera#e"tic Bood Ser"m
Le)es: @,; to 2,3 mE=/L #though levels of 1"0m-I7E are sometimes reIuired for control of acute symptoms$ 'hecked every
+ months
<nything above 1"2 to 1"0m-I7E is considered lithium toxicity
&ymptoms of lithium toxicity( lethargy and diBBiness
3f levels are very high an -N. will show significant changes T potentially fatal cardiac toxicity
:e aware of sodium intake T may lead to toxicity without a change in dose
Due to unwanted side effects, lithium is difficult to take over an extended time i"e" thirst and polyuria, tremor, weight gain,
chronic diarrhea #this is also an early sign of toxicity$
A medication usually taken indefinitely
AAA &alt and liIuids in a diet is important to reduce risks of lithium toxicity
A6TI-A6MIETY DR8AS
#<lso used for short-term insomnia as they induce sleep and decrease the freIuency of awakening$
:enBodiaBepines #the KpamsL$(
i"e" Ranax, DiaBepam, ;alium, EoraBepam #<tivan$, 'lonaBepam
DiaBepam and ;alium have long half-lives C are better for longer treatment plans whereas <tivan and 'lonaBepam have
shorter half-lives C are good for intermittent symptom-driven treatment
Ma' #rod"ce de#endence
&ide -ffects( sedation, occasional amnesia, physical dependence
A6TI %SYCHOTIC DR8AS
.iven to control symptoms of psychosis #( a state in which an individual has lost the ability to recogniBe reality$ #i"e"
hallucinations, biBarre behavior C paranoid behavior$ and prevent relapse" 8hey produce a claming effect without sedating
the pt"
&pecific Drugs(
aldol #aloperidol$
'loBapine #'loBaril$ T an atypical anti psychotic for treatment of schiBophrenia C bipolar psychosis
'hlorpromaBine
<typical ?euroleptics #i"e" 2isperidine C 9lanBapine$ are preferentially used as initial treatments for clients with previously
untreated psychosis
&ide effects in 1
st
few days( frightened expression and difficulty pronouncing words" 8hese indicate an acute dystonic
reation, which are reversible with antiparkinsons drugs #ie"benBtropine mesylate or cogentin$
&ide -ffects( constipation, dry mouth, blurred vision, postural hypertension, urinary hesitation or freIuency, weight gain,
sedation
&erious <dverse -ffects(
<kathisia #most common$( sense of restlessness with a perceived need to pace or move continuously #easy to be mistaken for
anxiety or agitation$
Dystonia( sustained, involuntary muscle spasms, commonly of head C neck
9culogyric 'risis( extraocular muscle spasms forces the eyes into a fixed, usually upward gaBe
8ardive Dyskinesia( a neurological disorder characteriBed by involuntary movements, most commonly tongue and lips
#grimacing7sucking movements7lip smacking$
Neurolpetic Malignant Syndrome (seen -ith all anti psych meds)/ sudden #e!er0 rigidity0 tachycardia0 hypertension0
decreased L23 1 death may occur ("reatment 4 stop psych meds and administer anit'parkisonian meds)
,,, antidepressants can take upto ) -eeks to kick in
6orma La- (a"es
L86AS:
blood p( 4")0-4"40
p'92( 20-40
'9)( 2!-24
LI(ER:
P8-3?2( !"@-1"1
P88( 2)-))seconds
Protein( +)-44
<lbumin( )F-0)
8RI6E:
,rine p( 0-F
spec gravity( 1"!1!-1"
BLOOD/ CARDIAC E6FYMES:
b #male$( 1)+-14! #female$( 12!-10!
>:'( 4"!-1!"0
8roponin( !-1"01yoglobin( !-F0
'N1:( !-F
DID6EYS:
Potassium( )"0-0"!
&odium( 1)0-140
,rea( )"!-4"0
'reatinine( +!-11!
'hloride( 1!1-111
:icarbonate( 24-)
CBCJ >:'/s, hematocrit, hemoglobin, 2:'/s
eectro'tesJ ?a, N, 'l
Didne' $"nctionJ N*8, creatinine, :,?
Bood Administration/ Reactions
1$ wear gloves at all times
2$ ;itals done immediately before transfusion, in 0 minutes, and in 10 minutes, then hourly throughout transfusion
)$ :lood to be administered thru primary line, not piggybacked
4$ ?& at 0! mls to establish 3;" <lways needs to be a bag of ?& and tubing at bedside
0$ :lood to be administered through 2! gauge or larger 3;
+$ 2E, D0>, half ?& cannot come in contact with :lood
4$ 3f ?& is to be added to blood, must have Dr"s order, and no more than 0! mls to be used, and it must be added
311-D3<8-EO before transfusion
F$ 3* dr/s order, *roBen plasma, stored plasma, 0% albumin can be added to packed 2:' immediately before transfusion
@$ 3f blood not hung immediately, return to bank within )! mins of sign-out time
1!$ Do not put blood in any other refrigerator
11$ usual time is 1"0-2 hours to infuse" 'annot take longer than four hours" 3f not transfused within 4 hours, D' and
discard in biohaBard bin" ?otify Dr" of amount transfused"
12$ 'hange transfusion set after each unit"
1)$ Do not flush tubing after administering blood
14$ 3nfuse blood slowly for the first 10 minutes
10$ >hen infusion more than one unit, attach an extension set 3;3, to decrease manipulation of site" >hen all infusions
are dome, 1,&8 remove extension set
1+$ < transfusion reaction report must be filled out for both 13?92 and 1<\92 reactions and top 2 copies are sent to
transfusion services
14$ Pt/s should be on bed rest during transfusion" 3f they need to leave the ward, they are to be accompanied by an 2?
1F$ Pressure infuser cuffs to be used when ordered by D2" for rapid infusion #ie" emorrhage$
1@$ 8ransfusion services to be called asap to cancel any previosly ordered blood that is no longer needed"
Bood Trans$"sion R.Hs: can happen during, immed" after or up to 4 days after infusion
2, Hemo'tic: <:9 incompatibility, chills, shakes fever, flushed skin, flank pain, stop transfusion, 8N;9 with ?7&,
call Dr" stat, monitor ;&, 379, bleeding, repeat type and cross match
3, Fe-rie: an ]1 degree ' with no other medical reason, blood is contaminated with bacteria, similar s7s to hemolytic,
stop infusion, 8N;9 with ?7& , call Dr stat, can occur within 4 hours of start of transfusion
4, Aer&ic: mildWitching, chills, fever, ?7;WHust &E9> D9>? transfusion" &evereWtight chest, diff"
swallowingW &89P 3?*,&39? call Dr stat, kiss your career goodbye"
ARO/8ni)ersa %reca"tions:
-private room or with pt" >ith same <29
-isolation sign on door
-wash hands with chlorhexine
-if <29 is 12&<, wash pt Iweekly with chlorhexine
-gown gloves and mask
-out of room procedure( write isolation and precautions on reI, and notify dept"
-needs three consecutive negative cultures from all sites taken when off antibiotics
SC B"tter$':
-prime with highest concentration of med #i"e" 1!1g7ml if hydromorphine$
-mark on tegadern date of insertion, initials, and dose concentration
-change I4d unless red7inflammed
C(C
-transparent drsg change I0d
-gauBe7mepore drsg change I2d
- 1ost common complication6 air emboli, therefore regularly check for chest pain, C dyspnea
-cap change I0days*lush unused lumen 9D with )cc syringe
-AAAnotify D2" if movement more than 0cm 92 1!cm or less of ';' internally
-To dra+ -ood: flush with 1!cc ?& in 1! cc syringe, and draw back 1!cc for discard" >ith new 1! cc syringe, draw back
1! cc blood, then flush again with 1! cc ?&"
-To &i)e meds: flush before and after with 1! cc ?&
%ICC
'hange drsg I0-4d by 3; team
cleaning solution is 2% chlorhexidine
tip should be in superior vena cava
flush ports by 3;8
warm compress ofter insertion for 2! mins, then 83D
<ssess for roping, reddness, swelling, drainage
Document measurement
,se 12 cc syringe, flush with 0cc ?&, and flush with 2! mls ?& after with syringe larger than 12 cc"
8o give meds, flush with 0 cc ?& before and after in 12 cc syringe"
AAAensure blood can be aspirated thru catheter prior to infusions" 3f it can/t be aspirated, there is risk of pushing clot thru
catheter"
In$"ser:
3nfuser changes I42hrs by 3;8,
flush before and after use with )cc ?&
change main bag I24h
change tubing I42h and label
E#id"ra
change filter and tubing I)days
drsg change I0d with order or when leakin, with 2 people
change med bags I42hr
-if witnssed disconnect( both ends sterile and reconnect
-if unwittnessed disconnect( cover catheter with sterile gauBe, call anesthetist
-%CA: 'leaning shift totals at 1!! and 22!!
T"-e Feeds
-need baseline +7+!, serum glucose and albumin
-repeat I monday and thursday
-keep 9: up 1! degrees
-do not hang more than 4 hours of formula at a time
-aspirate for gastric residules, D9 ?98 aspitage if in duodenum or HeHunum
-flush with +! ml syringe #only after feedings, not before$
-flush before and after meds with 2! ml water
-flush and wash bag and tube I4h
-wt" pt" D weekly
-change bag I4Fh
T%6
-vitals I4h and s7s fluid overload
-call dr" if central line site inflammed or temp over )@
-on 3 and 9/s
-weigh mon and thur am
-change iv tubing I 42h
-notify pharmacy if 8P? order changes by 11!!
-:> daily R )d than I mon and thursday
-if 8P? no available, hang d1!> at 0!ml7hr
T%6 Com#ications
1" &
2" &epsis
)" hyperglycemia #most common$
4" hypoglycemia
0" osmotic diuresis( r7t hyperglycemia
+" fluid excess
4" fluid deficit
F" electrolyte imbalance
Restraints
&afety measures( ,se minimum restraint, educate family, assess appropriateness of restraint, apply appropriate restraint,
<viod putting it over 3;, 'heck for tightness, pad skin and bony prominences, document use, call bell in reach, bed in lowest
position, provide sensory stimulation, wheels on bed locked, release at regular intervals,
-thical issues( loss of personal freedom, loss of personal dignity, risk of inHury or harm to person
?ursing interventions before applying restraints( assess need, review agency policy, Dr"/s order5, explore alternatives, inspect
skin condition of area, explain purpose, obtain consent
S"ctionin&:
-suction while withdrawing
-consious pt" &hould be in semi-fowlers, uncounsious6 side-lying
%RACTICAL ISS8ES
Ste#s +hen short sta$$ed
- assess needs of clients, 2? take most acute
if tasks are delagated to 2'<7EP?, make sure to get verbal feedback in timely manner
3f the -2 is about to be overloaded, first activate on-call list
reIuest for extra assistance on the ward
3f a new nurse, or float nurse comes onto a ward with a new acute pt", review what should be assessed, and what should
be reported"
Con$ict reso"tion +ith sta$$
-always speak with colleague about unsafe, unethical behavior first
important to be able to disagree with each others ideas, but not the other persons competence #ie" K3 do not agree with
you on this particular pointL$
%rioriti/in& d"ties
<ssess( urgency of the situation, chain effect of problem, available resources, C time limits
Re#ortin& "nsa$e #ractice
3f a nurse observes another nurse contaminate the sterile field when inserting a foley, immediately inform them
3f you suspect another nurse has been drinking, report to nurse in charge
HEALTH CARE/ TRE6DS
Se$--reast e.am
should be done every month, especially in older women
Birth Contro
Ora Contrace#ti)es: 01 &ynthetic estrogen and some progesterone"
1onophasic6 day cycle, 8riphasic6 throughout cycle
:enefits( dysmenorrhea, anemia, Decreased P3D, Decrease of ovarian and endometrial 'ancer and cysts, breast diseases
&ide effects( ?ausea, >t" .ain, eadache, :reast tenderness, &potting, 3nfections, ypertension, Depression
'ontraindications( 0A-so"te1: :east-feeding, family istory of ';<7'<D, 8hromboembolic Disease, Eiver Disease,
;ag" :leeding", interfere with glucose metabolism, penicillin, barbiturates, tetracycline, 8ylenol, anticoagulants,
anticonvulsants" 0%ossi-e1: 9ver 4!, breast7;ag malignancy, D1, 3ncreased cholesterol, hypertension, mental
depression, migraine, obesity, seiBures, sickle cell, smoking"
SC Im#ants: 06or#ant1 + implants with synthetic progesterone, works over 0 yrs"
&ide effects( 'ost, wt" .ain, irregular" 'ycle, hair loss, depression, scaring"
?o sexual side effects, can be used in adolescence, or with breastfeeding, rapid return of fertility"
IM InGections: 0DM%A/De#o-#ro)era1* every 12 weeks, synthetic estrogen and progesterone, nearly 1!!% effective,
increase risk for 9<"
I8D!S: plastic inserted into uterus, can cause P3D, low cost
Barrier Methods: S#ermicide, Diaphragm #cause ,83/s$, cervical caps, ;ag rings, 1ale and female condoms
CR6BC Ethics
Sa$e* Com#etent and Ethica Care: ?urses value the ability to provide safe, competent and
ethical care that allows them to fulfill their ethical and professional obligations to the people they serve
Heath and Qe--ein& ?urses value health promotion and well-being and assisting persons to achieve their optimum level
of health in situations of normal health, illness, inHury, disability or at the end of life"
Choice ?urses respect and promote the autonomy of persons and help them to express their health needs and values and also
to obtain desired information and services so they can make informed decisions"
Di&nit' ?urses recogniBe and respect the inherent worth of each person and advocate for respectful treatment of all persons"
Con$identiait' ?urses safeguard information learned in the context of a professional relationship, and ensure it is shared
outside the health care team only with the personMs informed consent, or as may be legally reIuired, or where the failure to
disclose would cause significant harm"
P"stice ?urses uphold principles of eIuity and fairness to assist persons in receiving a share of health services and resources
proportionate to their needs and in promoting social Hustice"
Acco"nta-iit' ?urses are answerable for their practice, and they act in a manner consistent with their professional
responsibilities and standards of practice"
N"ait' %ractice En)ironments ?urses value and advocate for practice environments that have the organiBational structures
and resources necessary to ensure safety"
3f a nurse observes another nurse breaking a code, they should( follow can code of ethics, review existing policies, review
private legislations, discuss with collegue, inform nurse-in-charge, in-service to revie confidentiality pronciples
%rinci#es o$ Comm"nication
-,se open ended Iuestions,
-<ctive listening,
-paraphrasing
reflecting
exploring
silence
clarifying
eye contact
body language
circular Iuestions
Determinants o$ Heath
1" 3ncome and &ocial &tatus
2" &ocial &upport ?etworks
)" -ducation and Eiteracy
4" -mployment7>orking 'onditions
0" &ocial -nvironments
+" Physical -nvironments
4" Personal ealth Practices and 'oping &kills
F" ealthy 'hild Development
@" :iology and .enetic -ndowment
1!" ealth &ervices
11" .ender
12" 'ulture
EMTRAS
Tr"ndeen-er&: head down [[[[[[
Sims #osition: < semiprone position with patient on left side, right knee and thigh drawn well up, left arm along patientMs
back, and chest inclined forward so patient rests upon it" 3t is the position of choice for administering enemas, because the
sigmoid and descending colon are located on the left side of the body"
%rosta&andins: act as messengers involved in reproduction #contractibility of the uterus$ and in the inflammatory response
to infection" <spirin inhibits prostaglandin synthesis, leading to reduced inflammation"
D"m#in& s'ndrome: 2apid gastric emptyingW happens when the lower end of the small intestine #HeHunum$ fills too
Iuickly with undigested food from the stomachWnausea, vomiting, bloating, diarrhea, and shortness of breath"
-encourage the use of antiseptic mouthwash to a client with neutropenia fromchemo, as mouth is primary source of infection
< child comes into -2 with sore throat, fever, drooling, and odd voice, stridor on inspiration, barking cough, and hoarsness"
D9 ?98 do visual exam of mouth and throat, as it may start laryngeal spasm, D9 prepare hight-humidity croupette"
-transfering a pt5 1ost important info is currant status, meds, and concerns"
) measures that a nurse could take to assist a pt" >ith their discharge(
involve her in all decisions
explore her feelings and thoughts about discharge
explore her perceptions of family support"
-?ursing interventions in health promotion programs are more effective if the nurse first finds the individuals definition of
health
-< pt" &tates they take herbal meds" 8hree ways to show respect for this( 1$add to care plan, explore choice, communicate her
choice to care plan, support her choice
2 potentially harmful effects of herbal remedies are( adverse7side effects, interactions with other medicine or food,
toxicity
) ways to increase knowledge about holistic healing modalities( ask Dr, search 3nternet article, books, review nursing
literature, review currant research, continuing education"
to involve pt" 3n development of holistic care plan( 1$ explain purpose of plan 2$ believe the client )$ assess present pain
control stratagies, include family, identify clients priorities, discuss past expereinces, provide information, encourage
expression, answer Iuestions
Afactors that may cause change in urine( new meds, new foods, new products, dehydration, hematuria
nurse can promote normal urinary elimination with a ,83 by encouraging( good perineal hygiene, fluid intake,
compliance with drug therapy, avoid caffiene, alcohol, lemon Huice, and spicy, avoid bubble baths, wear cotton underwear,
>est ?ile virus can be prevented by applying a D--8-based insect repellent to exposed skin"
<ppropriate use of services is a Primary health care principle"
'auses of ?ausea( <nxiety, Pain, morphine
tips for dealing with pt"s with aphasia( active listening, be patient, don/t interrupt, ask simple Iuestions, allow for adeIuate
response time, use visual cues, encouragement, communication aids, minimiBe distraction,
a pt" 3s reIuesting a new analgesic" 8he nurse shoulf 1
st
assess the pain using pain scale, call dr" regarding the assessment,
and then ask for new med orders
- after abdom" &urgery, a pt has to D: C ', spling insicion with pillow, and place pt on side with pillow between flexed legs"
C8LT8RE
always assess the degree of acculturation of a client when developing care plan
respect the personal spacce during pt interactions, as it influences the meaning of the message
8hree cultural traits on ?ative <mericans to assess when assessing pain( ?9 eye contact, use of traditional healing
practices, do not report pain, do not reIuest pain meds, speaks slowly, personal space
asses perceptions, biological practices, family roles, communication, health-related cultural practices, expression of pain,
self-medication-eating habits, religious practices, social organiBation
AAA sign of increased intercranial pressure in adults6 increased systolic :P, decreased pulse
priorities in comfort care( hygein, comfort, emotional support, rest
- hypercapnia( buld-up of co2 in blood, may oocur with spontaneous pneumothorax" Pneumothorax causes unilateral chest
pain, and mediastinal shift towards uneffected side, as well as decreased chest motion"
em#o+erment in a &ro"#/comm"nit' can -e esta-ished -':
establishing partnerships, mobiliBing a group leader, train trainers, establish a dialogged, and show the benefits
- to give a ventrogluteal 31, the nurse should( 1$place heel of hand over greater trochanter of femur, and 2$form a ; between
index and third finger