Nclex Rn.2018

NCLEX- RN
REVIEW NOTES 2018
Anonymous
USRN
KEEP OUR FRIENDLY LITTLE SECRET
CONTENTS
Few Tips and Mnemonics Included
Fundamentals of Nursing
Neurology & Sensory Disorders
Endocrine System
Gastrointestinal System
Genitourinary System
Respiratory System
Musculoskeletal System
Hematology
Immunology
Cardiovascular System
Psychiatric & Mental Health Nursing
Pediatric Nursing
Nursing Issues
Oncology
Integumentary
Maternal & Child Nursing
More reminders/notes
SERIOUS
ALERT:
If you have this file, PLEASE READ!!!!
RULE:
NEVER EVER DISCLOSE THIS TO ANY

REVIEW CENTERS, just keep it for
yourself.
CONSIDER THIS AS YOUR OWN

NOTES. If you are confused with some
topics verify it with your books or any
materials you have trusted.
You may share it to your friend or anybody

who needs it but remind them the golden
RULE.
Let us protect the one who compile this for

you! PLEASE KEEP YOUR PROMISE.
You may verify the topic but never ever tell
them cause this notes says blablablah
believe/trust what you want to….let us go
back to the primitive side.
KNOWLEDGE IS ALWAYS FREE

UNTIL PEOPLE MAKE IT A BUSINESS.
Unfortunately, some of us can’t pay for the

review for any other reasons. The essence
of NURSING IS CARING & SHARING.
So, let us renew our hearts content. As
much as I would love to hear your
feedback. I removed my email for security
purposes.
May this will help you.

Real talk! restart, I am not dying so my game is not over yet.
😋.
Hello! fellow nurses! NCLEX is expensive! But our
hard work will pay off soon, success is at hand for We must prepare in a different way this time. Make a
those who strive. I made a promise to myself to do commitment. Have enough time to prepare. Apply
this once I pass. I hope I can help you with the nursing process. Assess our strategies. Diagnose- time
content. If you are a 1st taker I hope you can PASS management. Plan for the next battle. Intervene, study
right away with a little help from me. with Comprehension, Practice! Practice! Don’t rush,
tendency is that we overlook the minute details which
For repeat test takers do not despair, there is hope. is very important (Avoid, Best, Further teaching etc.)
You are not alone. I have been through a lot of And Evaluate yourself. If information is overloaded!
hurdles from start to finish. We must control our STOP! Do the things that inspire you! then Go back
thought as it is so powerful. They said a real warrior fresh, to study.
never quit, winners never quit which is true! we don’t
fail in life if we keep on trying, you will only fail, for If you don’t get the scores that you’re looking for
real once you QUIT. Fighting! We can do this! while you study, shake it off and move on, it only
means we must keep studying and practice more. If
Oh! well allow me to share my story. I graduated long you feel like you can absorb better solo or within a
ago. It's been a while before I decided to take the group session/classes, then do it! Suit yourself
exam. I failed twice! I must pick myself up. I still got consider the setting! whatever you think will help you
lucky I have my family and friends with me 😍. So, out and make you at ease. Don't assume that you don't
we got you! I know the process is expensive, and so it know anything at all. you got this! you just need to
goes with the review materials. We don't know where refresh your memory.
to start. We don't know what to do. Whom to talk to.
No matter what people say to inspire us...it doesn't I am not super techie so pardon me. so as with my
make any sense at all. It's okay not to be okay but we grammar...lol. This will not replace any books. This is
have to fight! So, shake it off. I’d say I know how it merely for review purposes. Tried my best to compile
feels, been there, done that. It's like you have wasted this and add pics so it’s easier for you to create a
a lot__money, time, effort, etc. It's okay not to be mental imagery during the actual exam. If you dislike
okay when you do but it’s never okay to give up, the color, feel free to change it, if you want to add
everything happens for a reason. notes please do so. I do not own this, it's an
accumulation of notes, strategies and techniques that
Life teaches us a lesson and here we are taking God's I’ve got while I study from different sources, some
exam every day as we explore in this world. are my own...you can use it if you think it is useful or
Experience is the best teacher. The world is so wide you can create your own mnemonic. It's a bit colorful
and life if too short. We must learn from our mistakes cause I am not the kind of person that enjoys reading
or else we will fail over and over. I hope you will that much (not my thing) so I must make it fun for my
learn from mine. Chances are thousands, let us use it eyes to read and I use black background so it’s not too
wisely. When I was down. I must reassess what's bright. You may change it, whatever your preference
missing, what are my mistakes, instead of using my is.
beloved defense mechanism Rationalization and
Projection plus procrastination. And so, IT WAS MY None of this is a guarantee, everything is still up to
FAULT. I should never blame anybody. I just have to you! This is not about spoon feeding, this is merely
for review purposes. This is not a guarantee, but it
might help you. I must remind you, you still have to
help yourself, honey. I should say none will help us if
we study NCLEX literally, no matter how good the
review materials we have, we must comprehend,
analyze and understand the principles. Be like a spy
look for cues. So, give it your best shot!
I'd really hope I will be able to help you reach your

goal. And we will together continue to serve and help
people live healthier lives.
Do your best, God will do the rest! The strongest

weapon in every battle is PRAYER!
“Whatever you do, work at it with all your heart, as

working for the Lord, not for human masters, since
you know that you will receive an inheritance from
the Lord as a reward. It is the Lord Christ you are
serving.” (Colossians 3:23-24).
2 Timothy 4:7. I have fought the good fight, I have

finished the race, I have kept the faith.
TipS
If you may install this
app and as much as
possible answer at least
25 questions each day, make it
a habit, no need to unlock or
purchase and the
content is almost
the same as this app OR whatever Q&A
books/app works for you…
Practice looking for hints/cues, improve your
strategies, techniques and hone your skills. Then for a
week or two practice Q&A for 265, timed! Increase
your endurance
*Just familiarize the *If the question is talking about an injury
anatomy ;) Think about what site is affected?__(cervical)
We can use this if we Possible effect?__ (difficulty breathing, complete
dissect the questions ☺. paralysis below the neck)
Unfamiliar question? don’t
rush make an educated *If you are confused about the effects of the drug
guess, I know you can, I (only if you do not know, use critical thinking), ask
believe in you! yourself
every Q & A count. -is it an excitatory drug? Then S/E__SNS, A/E__PNS
-is it an inhibitory drug? Then S/E__PNS, A/E__SNS
*What I meant about dissecting ;) “-ectomy” – so it is Ex: Epinephrine (excitatory)
talking about removal of something.
*Make something like *Remind yourself that NCLEX is book base/nursing
this: theory, it’s not about our personal experience.
Caput succedaneum – it
succeeds - crosses the * What if? STOP! Focus on what the question is
suture asking, be alert with the setting. In the exam you have
Cephalohematoma – do everything you need. staff, materials, etc. It is a
not cross perfect world. Your client in the only person
Nursing is an art! So be presented in the question. Stop overthinking
creative everything.
*If the question is talking about RUQ then it is
talking about the liver, so just familiarize what organs *Try to create a mental image
are in that specific quadrant (location)? Functions? of the anatomy, diseases,
procedures, terminology and
theory. This will also help you
with the hot spot (?) Skim and
scan, then go back with the Q
& A to improve your training
as a spy ;)
*If the question does not have data in it, then answer your exam in the morning then practice in the
will most probably be about assessment, if it’s present morning of otherwise.
then move on_ it probably requires intervention.
ANALYZE *For SATA_answer it like a true or false in each
*Don’t expect to get everything right, to know all. choice. Verify if negative/positive query.
The harder it gets then the closer you are.
*Don’t expect to complete at 75, expect for 265. So
*Don’t just choose answer choices based on a you won’t despair if it won’t stop at 75 you are still in
hunch/feeling, apply your nursing knowledge instead, the game, and to just answer the question to get
recall the principles. NCLEX is not merely about through the rest of the exam.
identification, so memorizing might not
work…Please ANALYZE. Let us use our Critical *If there are topics that confuses you JOT it down
thinking skills. and read it over and over REPETITION with
COMPREHENSION is the key (have a pocket
*Familiarize yourself with the computer adaptive test notebook). Again, Scan and Skim.
*Visualize yourself as you read through the Q & A
*Umbrella question_ answer that covers all of the *During the exam they will
others provide you with an erasable
*Consider all choices, do not predict, then use the board and pen. Make use of
process of Elimination to narrow down your options. it. This is very important. It
*Identify if it is a negative/positive question_ write is provided for a reason.
(-) / (+) Imagine of it as if you are asking a friend for
clarification. Think of it as me ☺.
*Tricky words_ALERT_avoid, further teaching, 1st what are you going to write__ex. (-) Needs further
(so it means you can still do the other options, but teaching_Cushing? So you will now look for the
which one is 1st among the choices) best (all are Negative query. It will remind you about what the
correct, but you must select the highest), etc. question is really asking.
*Familiarize proper delegation *Don’t be lazy during the exam. Think hard.
*Decide which patient is sickest/healthiest Remember this is what you are preparing for. Your 6
Answers always have age, gender, dx and hour-time frame will decide. So, give it your best
modifying phrase (most important) shot!
*During the exam if you become fatigued take a
*PRIO – will the result be worse? break and a snack. Bring a dark chocolate whatever
Unstable vs Stable helps you.
Unexpected vs Expected *A day before the exam, pamper yourself. Prepare for
Acute vs Chronic your big day! Feel fresh and comfy.
Physiological vs Psychological *Write your name with RN in the end. Claim it!!!
Maslow’s hierarchy
ABC Jeremiah 29:11
Nursing process For I know the plans I have for you,” declares the
Safety Lord, “plans to prosper you and not to harm you,
*Select the time of the day that you test your best, plans to give you hope and a future.
wherein you can absorb better. Or If you schedule
FUNDAMENTALS OF NURSING TONICITY OF IV SOLUTIONS
1. Fluids and Electrolytes Tonic – concentration of solution Tonicity

➢ Risk for Imbalances: Opposite with
1. Hypotonic - tonicity of the cell the Prefix
• Infants - 80%
• can lead to cell lyses
• Male – 60 %
• produces cellular swelling
• Female – 50 % *(more body fats)
• osmosis, movement of water into the cell
• Elderly – 40 %
• for patients cause: DKA, hyperosmolar
2/3 – ICF
hyperglycemia
1/3- ECF – intravascular & interstitial tissues
• Avoid: patient with ICP, burns, trauma
• ex. Dehydration, Fluid Vol. Deficit
2. Cellular Transport
• ex. 0. 33 % NaCl *(almost all <1/with point)
➢ Passive – No energy
0. 45 % NSS
• Osmosis – Movement of H2O from lOw to high
0. 22 % Saline
concentration
D5W (inside the cell)
• Diffusion –*(diffuse) Movement of solutes
from high to low concentration.
➢ Active – Uses energy (ATP)
• Na+ and K+ pump
Impulses contraction 2. Isotonic – equal, no cellular change
• fluid maintenance, replacement for patients
Na+ Na+ K+ with burn, dehydration due to N/V
Ca+ K = • ex. 5% dextrose in 0.225 Saline
Ca+
+ PNSS
= PLR (burn)
Repolarization
+ = Depolarization D5W (outside isotonic)
Relaxation - Contraction
➢ Pressure =
• Oncotic – pulling force, prevent leakage of
-
fluids that causes edema or ascites
=
Albumin- balancing act 3. Hypertonic - tonicity of the cell
=
• shrinking of the cell, movement of water out
=
of the cell
_
Pressure (artery) Albumin (IV) • ICF
+
• usually central line, mostly in ICU
Pressure (veins) • Watch out for or WOF: pulmonary edema
Ex: NephrOtic Syndrome damage to the glomerulus • ICP – give mannitol
(filter) • ex. D5050 * (not less than 1/ no point)
Nrsg Intervention: give IV Albumin D5LR - hyperglycemia
3 % Saline
• Hydrostatic – pushing force, to prevent 5 % Saline
hypertension.
Pressure (artery) Albumin (IV)
Pressure (veins)
FLUID IMBALANCE ➢ HYPONATREMIA
• cause: SIADH
1. Fluid Volume Deficit (FVD)
S/Sx: Neonate: sunken fontanels and eyeballs ADH
• flat neck veins
• dry poor skin turgor Fluid retention
• constipation
• oliguria Weight gain
• weight loss
• ex. shock (isotonic) Serum Urine
• V/S: Hypotension BP
USG opposite
• Tachycardia PR Hemodilution Oliguria with Urine
• Tachypnea RR Output
• Pulse pressure – Narrow - 90/60 Dilutional hyponatremia USG
*( N- 40 ); (systolic – diastolic = Pulse pressure) N – 1.010-1.030
• HCT - concentrated HCT Mgt: Demeclocycline (Declomycin)

*( N : M – 42 - 52 %, F – 35 - 47 % ) ________________________
• CVP – measure fluid balance - cause: Na
• CVP -
*( N – 5 - 10 cm H2O / 3 – 8 mmHg) H2O
Mgt: H2O = CVP
HCT Opposite with H2O
- IVF S/Sx FVD
- I&O replacement & monitoring Mgt: IVF
2. Fluid Volume Excess (FVE) ➢ HYPERNATREMIA

• periorbital or facial edema • Cause: DI
• distended jugular neck veins r/t ADH
hypOnatremia_Overload
• CHF ADH hypErnatremia_dEhydration
• Ex. ICP LOC
• V/S: Hypertension BP Fluid loss
• Bradycardia PR
• Bradypnea RR Weight loss
• Pulse pressure – widened - 140/90
- HCT - dilution Serum Urine
CVP –
• Lungs – Left Systemic – Right Hemoconcentration Polyuria
• pulmonary edema - edema generalized
• crackles / rales - ascites HCT Diluted
• DOB - weight gain
Hypernatremia USG
• coughing
3
Mgt. Diuretics
Mgt: Vasopressin
Dialysis
Desmopressin
Digoxin
Cause: Na
• replace albumin (IV)
ELECTROLYTE IMBALANCE H2O
1. SODIUM (Na+) – N 135 – 145 mEq/L S/Sx FVE

Mgt: Diuretics K+ foods
Digoxin Apples
Albumin Blueberries
Blackberries
2. POTASSIUM (K+) K+ = impulses Cherries
• Directly proportional impulses Grapefruit
N – 3.5-5.1 mEq/L Peaches
➢ HYPOKALEMIA = K+= impulses Pineapple
• CNS – lethargy
• HEART – T wave inversion/ depression, 3. CALCIUM – 4.5 – 5.5 mEq/L
U wave* 8.6 – 10 mg/ dL
• GIT – constipation • opposite with impulses

• MUSCLES – Early – cramping ➢ HYPOCALCEMIA = Ca+ = impulses
Late – weakness • Tetany
Mgt: replacement K+; oral kalium durule • (+) Chvostek sign – facial
IVF KCl muscle twitching
Kalemias is equal • No IV push always incorporate • (+) Trousseau sign – carpal
to the prefix • Never add more than 40 mEq/ L spasm
except heart rate • Never infuse in more than 10 mEq/L • Prolonged ST/QT interval
and urine output
• K+ rich diet WOF: laryngospasm (airway problem)
Potatoes (baked with skin) Mgt: diet – milk /dairy products
Apricot (dried) • IV calcium gluconate
Anything r/t
urination = K+ Banana • Oral calcium chloride/ carbonate
Orange Kiwi
Watermelon Cantaloupe ➢ HYPERCALCEMIA= Ca+ = impulses
Strawberries • Bones (brittle)- Ca+ cause it’s in the blood
• Avoid digoxin because it will lead to • Stones – renal calculi Alphabetical order
digitalis toxicity* • Moans – muscle weakness _Parathyroid –
• Avoid K+ wasting • Groans - GIT – constipation bone to blood
Bumetanide (Bumex) Mgt: Calcitonin (movement of Ca+
Furosemide (Lasix) – loop diuretic blood bones)
Hydrochlorothiazide Fosamax (bone mineralization)
Mannitol – osmotic diuretic Diuretics excess calcium excretion
➢ HYPERKALEMIA= K+= impulses Dialysis
• CNS – seizures • Shortened ST & widened T wave
• HEART – tall peak T wave 4. PHOSPHORUS – 2.7- 4.5 mg/dL
• GIT – diarrhea ➢ HYPOPHOSPHATEMIA
• MUSCLES: Early: spasm Ph – malnutrition / starvation / antacids
Late: weakness • alcoholism
Mgt: (Sodium polystyrene) Kayexalate – permanent to P inversely
K+ proportional - Ca+
➢ HYPERPHOSPHATEMIA
• Oral (powder, dilute in H2O), enema Ph – tumor lysis syndrome
• IV GI solution (D5050 with insulin) – • renal insufficiency
temporary solution/emergency cases
Avoid K+ sparing diuretics 5. MAGNESIUM Mg+ = impulses
Spironolactone • opposite impulses
Amiloride • N – 1.5 – 2.5 mEq/L
Triamterene
➢ HYPOMAGNESEMIA = impulses
CNS: Brain – seizure Step 3: Compensation???
Spinal cord – hyperreflexia + 4 (N +2) If Normal pH: Fully compensated
MUSCLES: Spasm If abnormal pCO2 or HCO3 but pH is abn – Partially
Tetany If Normal pCO2 or HCO3: Uncompensated
Cramps Compensation:
HEART: V tach* Respiratory Acidosis & Alkalosis
• pH is normal (compensated)
Polymorphic VT (Torsade’s de Pointes) • HCO3 is abn (partial compensation)
• Tall T waves and depressed ST • HCO3 is normal (uncompensated)
Mgt: MgSO4 IV Metabolic Acidosis & Alkalosis
Mg Salts p.o. • pH is normal (compensated)
• paCO2 is abn (partial compensation)
➢ HYPERMAGNESEMIA= impulses • paCO2 is normal (uncompensated)
DTR (-) or absent
Normal Values:
Respiratory –
Oliguria pH 7.35 – 7.45 PRIO
PaCO2 35 – 45 mmHg pH < 6
bP decrease HCO3 22 – 26 mEq/ L
PO2 < 60
Mgt: Calcium gluconate (antidote Mg toxicity) paO2 80 – 100 mmHg
SaO2 95 -100 % PCO2 > 60
Diuretics
Dialysis
O2 (mechanical ventilator) Ph 7.5 Uncompensated
• Prolonged PR PaCO2 32 Respiratory
• Widened QRS complexes HCO3 26 N Alkalosis
Ph 7.37 N Fully compensated
Add note : N Cholesterol 200 mg/dL PaCO2 32 Metabolic
HCO3 19 Acidosis
ABG (ARTERIAL BLOOD GASSES) Ph 7.33 Partially compensated
PaCO2 46 Respiratory
✓ Patency radial and ulnar artery -Allen’s Test
HCO3 30 Acidosis
a. Occlude both radial and ulnar artery
INTERPRETING ABG
b. Close and open hands 3 times
c. Release ulnar artery Respiratory Metabolic
d. Access perfusion hands CO2 = acidic HCO3 =
alkalosis
Acidosis – pH PCO2 K+ HCO3 K+
Ex. COPD, Clients with lactic
Obstruction acid
r/t hypoventilation DKA
As the pH
Asthma- late sign Renal failure
goes…so as my PRIO: MS, MG, GBS, MI
pt Except K+ ALS Burns
PRACTICE DRILLS: ABG INTERPRETATION Comp. Respi. Diarrhea
Paralysis Mgt: NaHCO3 IV
Mgt: Deep breathing
Step 1: pH Acidosis Exercise
Alkalosis Purse lip breathing
(inhale nose, exhale
Step 2:
mouth)
Respiratory Alkalosis – pH PCO2 K+ HCO3 K+
Opposite Hyperventilation Vomiting
Asthma – initial sign Continuous NGT
Metabolic Anxiety, Panic attack drain/ suction/lavage
Equal Mgt: Brown bag Antacid overdose
Method Mgt: Diamox
Partial rebreather mask Aluminum HZ Herpes zoster (shingles)
(reservoir mask) Chloride -initial airborne, if with lession contact
Contact- gloves and gowns
CHEST DRAINAGE SYSTEM Cholera
Clostridium difficile – diarrrheal dse
• Dislodged ( Patient ) Rotavirus; * RSV (Respi. Syncytial Virus)
✓ Cover with sterile vaselinized gauge/petroleum
(?best) ; (?1st) cover with gloved hand be Alert, stay
Impetigo
• Disconnected (tubing) FOCUS, look for Bronchiolitis causative agent
✓ Immerse tip into bottle of sterile H2O (?best); the cues/hint
(?1st) clamp MRSA (Methicillin resistant

• CTT removal – exhale and bear down/valsalva staphylococcus aureus)
VRE (Vancomycin resistant enterococcus)
Hepatitis B/C/D/F/G (blood-consonant)
Droplet –simple surgical mask, 3 ft distance
Diptheria
Rubella (german measles) 2 “L” 2 words
Oral pharyngitis
Jhj Drain/Collection H2O seal Suction chamber
Normal: Normal: Normal: Pertussis, Pneumonia
< 100 ml/hr 2 cm H2O Continous / gentle
Color: serous/clear, Gentle intermittent constant bubbling Erythema Infectiosum (5th dse), Epiglotitis
Serous sanguinous bubbling/ due to (-) pressure
fluctuation. Tonsilitis
WOF : purely blood Constant/continous WOF: vigorous
(bleeding) bright red/ - leak Influenza (flu)
sanguinous No bubbling
- 1st 24 hours-kink Scarlet fever
? Insertion or obstruction
Apical – Air - after 24 hours Meningitis /mumps (parotitis)
Basilar – Blood Lung reexpansion Enteric- fecal oral route (gloves and gown)
OVERVIEW OF INFECTION PRECAUTION Shigella dysenteriae
Tier 1. Standard Salmonella
-Universal handwashing Hepatitis A/E (vowels)
- personal protective equipment SAFE DONNING AND REMOVAL OF PPE
(gowns, gloves, mask, goggles) Donning PPE Removing PPE
HIV and hepatitis 1.
2.
Gown
Mask
1.
2.
Gloves
Goggles
Infectious mononucleosis 3.
4.
Goggles
Gloves
3.
4.
Gown
Mask
*(kissing’s disease)
Tier 2. Trasmission Based MACRONUTRIENTS
Airborne – private room with negative pressure
✓ N95 mask, Hepa filter mask, high efficiency HIGH CARBS LOW CARBS
✓ calorie ✓ glucose
Measles (Rubeola) 1 “L” 1 word ✓ energy ✓ CO2 production
✓ for patients with Limit – DM , COPD
TB Mumps, Rubella
marasmus, Dumping syndrome
TB – transmission- droplet,
Varicella (chicken pox) airborne precaution *( fiber and Carb
hepatitis, kidney High protein) Coffee colored – bleeding *Report
dse 4. Flush
5. Feed
HIGH CHON LOW CHON 6. Flush
- albumin - urea –kidney
*during feeding: cramps- stop temporarily
✓ wound - ammonia-liver
healing/repair biproducts NGT SUCTION
✓ pt post op; burn - kidney failure ✓ Semi-fowlers
✓ COPD-source of - liver cirrhosis WOF: K+, metabolic alkalosis
energy - hepatic encephalopathy TPN
✓ Nephrotic LOC - subclavian vein (central vein)
syndrome Nephritic syndrome - jugular vein
- lean CHON r/t acute
(chicken, fish) no glomerulonephritis - maintain sterile technique
red meats, beef (Azotemia- BUN) - compatible substances
Glucose
HIGH FAT LOW FAT Enzymes
✓ - insulation - bile related Lipids
✓ - heat production - liver cirrhosis Amino acids
✓ - absorption of - peritonitis
WOF 1. Priority – Infection – sterile!!!
✓ VIT ADEK - hepatic encephalopathy
- cholelithiasis 2. Hyperglycemia
- cholecystitis 3. Air embolism
- post cholecystectomy
- CAD, MI
ENTERAL AND PARENTERAL NUTRITION
Bland diet Balanced diet Brat diet
NGT INSERTION - for pts with upper - for pts with Banana
✓ High fowlers GI dses – GERD, DM Rice
peptic ulcer Obese Apple
1. Assess nasal patency *(GI irritants) Tea/Toast
2. Lubricate the tip of tube (KY jelly)
NO Coffee ✓ boiled egg
3. Nasopharynx – instruct to tilt the head back Alcohol ✓ ground meats
4. Oropharynx- instruct to flex the neck then shallow Spicy X fried
*Gag reflex – stop Hot X milk
Limit fat
temporarily
*Respiratory distress- stop Low residue
- Lower GI disorders
and remove and wait till - Diarrheal dses
distress resolve CROHNS
Methods: Diverticulitis
✓ CXR – best method Gluten free diet Purine free diet Tyramine free diet
✓ Gastric content aspirate -for pts with celiac -for pts gout -MAOI’s diet of choice
dse uric acid stones for patients with
✓ Gastric pH- acidic 1-5; if ph > 6 = lungs depression lead to
✓ Insufflation NO Barley NO hypertensive crisis
✓ Least commonly done – immerse the tip of the Rye, flour Anchovies -levodopa
Oats Lentils -migraine
tube in the glass of H2O Wheats Legumes
✓ Normal- No bubbling Beers/beans AVOID
✓ rice Nuts aged, processed,
✓ With bubbling- lungs ✓ corn Organ meats fermented, pickled,
NGT FEEDING Yeast smoked, cheese. ALL
✓ Semi-fowlers Sprouts cheese except cottage
cheese
1. Assess bowel sounds
2. Placement - pH
3. Residual volume Normal < 100 ml/hr
BASIC LABORATORY PROCEDURE 3. Sigmoidoscopy (lower) – usually enema 1 hour
➢ RADIOGRAPHIC prior to the procedure
1. Barium (GIT) Pre-pro empty the bowel, left lateral.
A. Swallow (upper GI series) NPO 6-8 hours
Pre-pro = high fowlers, NPO 6-8 hours Post-pro = same Colonoscopy
Post-pro = S/E: constipation chalk like LUNGS
stools 1. Bronchoscopy
Mgt: OFI Pre-pro = supine, NPO 6-8 hours.
B. Enema (lower GI series) Pre-meds - lidocaine spray
Pre-pro = Left Sim’s, NPO 6-8 hours Post-pro = same EGD
Post-pro = S/E: constipation chalk like MEDICAL SURGICAL POSITIONS
stools Position
Mgt: OFI Procedure During After
Thoracentesis Sit, leaning forward
Lobectomy Unaffected side
2. Iodine (GUT) Segmentectomy - to promote lung
-IVP or intravenous pyelogram Eye cataract surgery Expose Site expansion (lungs)
-to prevent bleeding
Pre-pro = supine or flat on bed, (eyes)
NPO 6 - 8 hours, Pneumonectomy Affected side
Ask allergy shellfish Comp: tracheal
deviation
Post-pro = S/E warm and have salty taste Lumbar puncture Side, Knee Chest
Mgt: OFI Lower spinal surgery Supine
Cervical spinal -to prevent CSF
Complication: for BOTH surgery Prone leakage
WOF Anaphylaxis can cause airway problem Infratentorial surgery
(nape)
(craniotomy)
➢ ENDOSCOPY Supratentorial Semi-fowler Semi-fowler- to
GIT surgery (hairline) prevent ICP
1. EGD or esophagogastroduodenoscopy (upper) (craniotomy)
Liver biopsy Left side/supine Right side- to
Pre-pro = left lateral, NPO 6-8 hours, (RUQ) prevent bleeding
Pre-meds - lidocaine spray Gastrectomy Low to semi
Supine fowlers- to relax abd
* ( gag, atropine) tension
Post-pro = assess for gag reflex Cardiac Supine with the
Bowel sounds catheterization affected leg straight
4°-6° to prevent clot
Flatus formation/ bleeding
WOF: perforation Amputation Expose site 1st 24°-elevate to
prevent edema
2. Colonoscopy (lower)
After 24°-prone to
Pre-pro = clear liquid foods only, stop clear prevent contractures
liquids 4 hours prior, empty the bowel, left to easily attached
prosthesis
lateral.
Post-pro = Bowel sounds & movement
Condition Position
Flatus, contact provider-feeling bloated, Arterial disorders – too low Dependent position (low)
N/V, fever perfusion
Venous disorders- too high Elevate
WOF: perforation,
perfusion
problems passing urine, Increased ICP Semi-fowlers position
abd becomes tender and - head neutral
COPD High fowlers position
hard, stools are
black/blood, vomit with
WOUND HEALING & CARE
blood/bile
-diet: Protein and Vit. C
NATURAL -hospital ward – room nearest to the
PROCESS:1. station
Hemostasis B. Visual acuity: Presbyopia (farsightedness)
- Control bleeding - Notify the Dr to prescribe reading glasses/
- macrophages convex lenses
- clots C. Hearing – Presbycusis
- platelets ✓ Do not shout/ pitched tone; normal tone
2. Inflammation and stand in front of the patient
- bradykinins, prostaglandins, histamines D. Lung residual volume- weakness of
- 1st 3 days diaphragm – Risk for pulmonary disorders ; flu;
- vasodilation pneumonia and influenza
- redness E. Clotting – MI/ CAD/ CVA
- swelling F. Color difficult to be distinguised: Purple
- pain ✓ Easiest - RED
3. Proliferation G. Bone deminiralization – osteoporosis
- 3rd day onwards estrogen Ca+ rich diet;
-granulation Ca Supplement Fosamax
-contractions H. Gastric enzymes: indigestion constipation
-epithelialization OFI/ fiber ; do not abuse laxative lead
4. Maturation/Remodeling to constipation
- collagen synthesis (scar formation) I. Bladder capacity: shrink Incontinence
Kegel’s exercise
1st_red/no vesicles J. GFR: drug toxicity
2nd_red/shiny/with vesicles/wet K. No taste buds – dulled tatse tendency
3rd_white/hard/dry Salt hypertention
DECUBITUS/PRESSURE ULCER MEDICATIONS AND CALCULATIONS

- Turn every 2 hours PARENTERAL MEDICATIONS
Skin Disturbances Injection Best Site Angle Gauge
Route (needle)
Skin Characteristic Dressing Intradermal Forearm 10°-15° 25-26
I Intact, redness Tegaderm (ID) max
II Opening to the Hydrogel Subcutaneous Abdomen thigh, 45° 22-24
dermis (most (SQ) arm
painful-nerve
Intramuscular Adult-Deltoid 90° 20-21
ending)
(IM) Pedia - Vastus
III Subcutaneous (not Hydrocolloid Lateralis
painful) (duoderm) IM__21 Ventrogluteal –
IV Bones & muscles Sterile foam & SubQ__25 large amount
cavity Sterile dressing Buttocks -upper
outer- prevent
Dehiscence- suture separation hitting sciatic
nerve lead to
Evisceration- popping out of internal organ paralysis
BOTH: Splint or support if pt cough Z track method *(in IM medications)
✓ Initial: low semi fowlers (1st) - prevent leakage & irritation & staining
✓ Cover with sterile moistened gauze (best) - ex. Iron (imferon) – dark brown color
✓ Notify Dr, V/S - do not massage
GERIATRIC NURSING
Dev’t Task: Ego Integrity VS Despair 65 yo
A. Cognitive decline: Alzheimer’s dse
Safety-long term care facility-name and picture
INTRAVENOUS FLUIDS 3. Heparin 20,000 units in 500 ml D5W at 50 ml/hr
VESICANT NON-VESICANT has been infusing for 5 ½ hours. How much
Ex. Chemo agents, IVF heparin the client received?
(Check patency vein, 1. Phlebitis- inflammation a. 11,000 units Calc. 20,000 U= 40U x 50ml
aspirate) There will be Vein, warm, redness, pain b. 13,000 units 500 ml ml hr
vein rupture ✓ Change IV 72°
c. 15,000 units = 2000U x 5.5 = 11,000
2. Infiltration- pain, cool,
Tissue leakage pale d. 17,000 units hr
✓ Remove & change
Burns (extravasation) IV site, apply warm 4. A client was ordered to be infused with 1000 ml of
Mgt: STOP! compress, elevate D5W in 12 hours. The drop factor is 15 per ml.
Notify Dr 3. Speed shock – too rapid The IVF must be set at how many drops per min?
adm. of IVF-distended Ans. 21 gtts/min Calc. 1000ml x15 =15000=21
(initial) veins specially
infants 12 hr x 60 min 120
Mgt: diuretics IVF rate
4. Air embolism- ml/hr = total vol (ml) x gtt factor (15)
restlessness LOC no. of hrs
Mgt: 1. Stop gtts/min = vol in cc x gtt factor
2. Position Left no. of hrs x 60 mins
Trendelenburg to trap the
Cardio drugs:
air
3. Notify the Dr Dobutamine, the constants are
4. O2 supply (100%) Single dose= 16.6 (translates to 250/250 or 500/500)
Double =33.3 (translates to 500/250 or 1000/500)
Computation:
Oral meds: solid (tablets or capsules) Dopamine, the constants are
Single dose= 13.3(translates to 200/250 or 400/500)
No. of tablets = Desired x tablet (med label) Double =33.3 (translates to 400/250 or 800/500)
Available
Oral/Parenteral Meds: Liquid form 5. A patient weighing 182 lbs was ordered to be given
DOBUTAMINE at 5 mcg/kg/min. The preparation is
Dose in mL= Desired dose x Dilution (med label) 500mg in 250 mL of D5W. How many ml/hr should
Stock dose the patient receive? How many ugtts/min should the
1. The order is to give Demerol (meperidine) 35 mg patient have?
I.M. q 4h p.r.n. for pain. The medication is Calc. 182/2.2 = 82.7 kg
supplied in an ampule marked 50mg per ml. How 500 x 1000 = 500,000 mcg
much of the medication should the nurse give? • 5mcg x 250 ml x 82.7kg x 60min=12.4ml/hr
Calc. Kg 500,000mcg 1kg 1hr
35mg x 1mL = 0.7 mL min
50mg • Dose x wt in kg x 5.82.7 = 12.4 ml/hr
Answer: 0.7ml Constant 33.3
2. A client is to receive 10 mEq of KCl diluted in
250 cc of normal saline over 4 hours. At what rate 6. A patient weighing 176 lbs was prescribe DOPAMINE
should the nurse set the client’s IVF pump? at 5 mcg/kg/min. The preparation is 400mg/250 ml in
a. 13 cc/hr D5W. How many ml will the nurse give in an hour?
b. 63 cc/hr Calc. 250cc = 63 cc/hr Round of the nearest whole number.
c. 80 cc/hr 4hr Calc. 176/2.2 = 80 kg
d. 125cc/hr • 5mcg x 250 ml x 80kg x 60min=15ml/hr
Kg 400,000mcg 1kg 1hr
min
• Dose x wt in kg x 5 x 80 = 15 ml/hr (1st 2/3 of the tongue)
Constant 26.6 VIII- Acoustic - Hearing - Sensory
IX- Glossopharyngeal – Swallowing - Both
NEUROLOGY & SENSORY Taste sensation
(last 3rd of the tongue)
DISORDERS
X- Vagus - Gag reflex, swallowing- Both
THE NERVOUS SYSTEM
Peristalsis
Central Nervous System
XI-Spinal Accessory – Shoulder Mov’t - Motor
1. Cerebrum
XII-Hypoglossal – Tongue Mov’t - Motor
a. Frontal lobe- thinking lobe (decision making and
planning), speech, movements, and critical
“Some Says Money Matters But My Brother
thinking
States Big Breast Matters Most”
b. Occipital - vision
“OOO To Touch And Feel A Girls Vagina Seems
c. Temporal – hearing, language memory,
Heaven”
comprehension
Mnemonic
d. Parietal – coordination of senses, orientation of
Cranial nerves
the body parts
Breakfast at 8
2. Cerebellum
Lunch at 12
✓ Balance, coordination of movements
Dinner at 5
3. Brain Stem
Early Breakfast at 5
✓ Respiration
Siesta at 1
➢ Autonomic *(Automatic)
✓ Involuntary
✓ Ex. Heartbeat, peristalsis, respiration
a. SNS (sympathetic nervous system)
✓ Fight/flight
✓ Epinephrine
✓ Dry
Peripheral Nervous System ✓ Adrenergic (Adrenaline)
➢ Somatic – voluntary
Mnemonic: face
b. PNS (parasympathetic nervous system)

✓ Water
✓ Rest and digest
Cranial Nerves ✓ Acetylcholine (cholinergic)
I – Olfactory - Smell - Sensory
II – Optic - Vision - Sensory
III - Oculomotor - Pupil di/constriction - Motor
IV – Trochlear - Eye Mov’t (arch) - Motor
V- Trigeminal - Corneal reflex, - Both
Mastication
Facial sensation
VI – Abducens - Eye Mov’t (lateral) - Motor
VII- Facial - Facial movement - Both
Taste sensation
SNS PNS Mgt.: General treatment
✓ Vasoconstriction ✓ Vasodilation ✓ Mechanical ventilator support
✓ Bronchodilation ✓ Bronchoconstriction ✓ Assistive devices
✓ Hyperglycemia ✓ Hypoglycemia ✓ Drugs: muscle relaxants
✓ Mydriasis ✓ Miosis (pupil
Ex.: Soma (Carisoprodol), Flexeril
(dilation) const.)
✓ GIT- constipation ✓ GIT- diarrhea (Cyclobenzaprine), Baclofen (Lioresal, Gablofen)
✓ GUT- oliguria ✓ GUT- polyuria -relieve muscle spasm
✓ Uterus-relax ✓ Uterus - contract 2. Guillain Barre Syndrome (GBS) *galing baba
DEMYELINATION DISORDERS ✓ Ascending paralysis
Autoimmune disorders ✓ Contributing factors - 2° to infection ex. Kissing’s
dse = campylobacter jejuni or Epstein-Barr virus
Immune system attacks your myelin sheath which S/Sx: Dyskinesia (earliest manifestation)
promotes scarring or destruction ✓ Clumsiness
✓ GIT & GUT
Impulse conduction ✓ Respiratory depression
✓ Dysrhythmias
CNS (MS) PNS (GBS) ✓ Dysphagia
General treatment: ✓ Facial weakness
1. Corticosteroids Mgt.: General treatment
2. IV Ig (usually Kawasaki Dse) ✓ Assistive device
3. Plasmapheresis ✓ Mechanical ventilator
✓ Removal of harmful antibodies in the system ✓ Antiarrhythmic – Amiodarone
✓ Monitor v/s and ECG
1. Multiple Sclerosis (MS) *mula sataas
✓ Common in female, age NEUROTRANSMITTER DISORDES
20-40, cold, Caucasians
(like snow white) 1. Myasthenia Gravis *(mata galing)
✓ Descending paralysis ✓ Descending paralysis
S/Sx ✓ Causes:
✓ Visual disturbances (early a. Autoimmune – immune system attacks
manifestation) ACETYLCHOLINE receptor sites.
a. Scotoma – central vision loss b. Cholinesterase – erase acetylcholine
b. Diplopia- double vision ✓ Dx test: Tensilon test
✓ Dysphagia ✓ Test anticholinesterase
✓ Respiratory depression (intubation) ✓ Short acting
✓ Ataxia- loss of coordination of movements ✓ Duration 3-5 min
Charcot’s Triad ✓ Route IV
✓ Scanning speech- slow talking with interruption of ✓ (+) if the
syllables weakness disappears
✓ Intentional tremors ✓ S/Sx
✓ Nystagmus – involuntary eye movement ✓ Ptosis – drooping eyelids - initial
✓ GIT ✓ Facial weakness
✓ GUT ✓ Muffled/hoarse voice
✓ Spasticity ✓ Dysphagia
✓ Lhermitte’s sign (barber’s chair phenomenon) – a ✓ Respiratory depression
sudden sensation resembling an electric shock that ✓ GIT
passes down the back of your neck into your spine ✓ GUT
after the flexion of the neck. ✓ Generalized body weakness/malaise
✓ DOC: - Neostigmine – more potent 3. Amyotropic Lateral Sclerosis (ALS)
- (Mestinon) Pyridostigmine - longer
acting ✓ Lou Gehrig’s
✓ PNS Mx (manifestation): WOF: dse- common in male
• Overmedication – ChOlinergic crisis ✓ Neurotransmitter
(watery) of Glutamine lead to
Teary eyes and salivation excitotoxicity affecting
motor neurons ONLY so
Give anticholinergic drug- atrOpine the memory, GIT and GUT
are still intact.
• Undermedication – Myasthenic Crisis S/Sx
✓ Fasciculations (earliest) – contractions of small
Exacerbation of S/Sx muscle fibers
✓ Hyperreflexia – exage reflex
” stigmines adm.” ✓ Spasticity
✓ Respiratory depression – intubation ONLY 21 days
2. Parkinson’s disease (PD) then use tracheostomy
✓ Dopamine ✓ Quadriplegia/ Tetraplegia – paralysis of all
✓ Disintegration of substantia nigra in the midbrain extremities
responsible for the production and release of ✓ Muscle atrophy, Tongue atrophy
dopamine Mgt.: Palliative treatment
✓ Inform the Dr if the patient has a plan to have a ✓ Est. Life span 5 years
baby/breastfeeding because it crosses the ✓ DOC. Riluzole / Rilutek – delay your ventilator
breastmilk dependency
S/Sx Summary Acth Dop Glutamine
✓ Cogwheel rigidity (earliest) MS GBS MG PD ALS
✓ Resting tremors (pill rolling) Autoimmune ✓ ✓ ✓ X X
Weakness X X
✓ Micrographia – penmanship that progressively
Pattern X X
decreasing in size weakness
✓ Mask-like facial expression
Earliest Mx Visual Dyskinesia Ptosis Rigidity Fascicu-
✓ Incontinence dis. lation
✓ Stooped posture Dysphagia ✓ ✓ ✓ ✓ ✓
✓ Bradykinesia Respi Dep. ✓ ✓ ✓ ✓ ✓
✓ Shuffling gait, small rapid unstable steps GIT ✓ ✓ ✓ ✓ X
✓ Advice to look straight ahead while walking (constiption)
Mgt.: GUT ( urine ✓ ✓ ✓ ✓ X
output)
✓ Assistive device
Add notes: neurogenic bladder – bladder atony
✓ DOC:
a. Sinemet {levodopa (converted to
dopamine) + carbidopa (preserve the levodopa Huntington’s disease
to prevent the enzyme from destroying it)} - Autosomal Dominant disorder (hereditary) – even if only
b. Symmetrel (Amantadine HCL) one gene is defective
Parlodel (Bromocriptine Mesylate) - Dopamine
Mirapex (Pramipexole) -Signs of psychosis
Eldepryl (Selegiline HCL) - Hallucination- sensing without
c. Ropinirole (Requip) – dopamine agonist stimulus
WOF: Signs of Psychosis - dopamine - Illusion- inappropriate sensing
of senses
- Delusion – wrong perception of oneself
- Delusion of grandeur (superior) Mgt.
- Delusion of persecution ✓ Corticosteroids
Mgt. ✓ Artificial tears- prevent corneal abrasions
✓ Anti-psychosis = Haloperidol (ok-pregnant) Health teaching – encourage facial massage/exercise
WOF: EPS -
✓ Dystonia – loss of muscle tone, poor posture CNS DISORDERS
✓ Tardive dyskinesia (irreversible) – jaw 1. SEIZURE
JITL swinging, involuntary repetitive facial - sudden surge of electrical impulse of the brain
movements, tongue protrusion, lip smacking, activity
✓ Akathisia – feeling of restlessness - it’s just a manifestation not a dse
✓ Pseudoparkinsonism – Mx bradykinesia, Seizure disorders
BRiT
rigidity and tremors–tx Benztropine a. Epilepsy – a repetitive seizure
(Cogentin) b. Status epilepticus – seizure episode that last for
✓ - Acetylcholine more than 5 min.
✓ Memory loss/dementia - recurrent seizure without going back to the
✓ Mgt. Cognex (Tacrine), Aricept (Donepezil), baseline (awake-seizure-unconscious-then seizure
Namenda (Memantine HCL) again)
✓ Chorea – involuntary dance like jerky movement Causes of seizure
✓ Mgt. Tetrabenazine (Xenazine) ✓ High grade fever, brain trauma, tumor, infection,
substance abuse or toxicity, severe hypoglycemia,
CRANIAL NERVES DISORDERS electrolyte imbalance - Na+, idiopathic
1. Trigeminal Neuralgia – tic douloureux (unknown)
Cranial nerve #5 Seizure category
✓ Impulse of CNS a. Generalized – sudden impulse is initiated on the
✓ Triggers entire brain
✓ Hot/cold food Type:
✓ Hard food • Tonic-clonic - Grand mal seizure
✓ Facial stimulation • Absence seizure – Petit-mal
✓ Sudden behavioral arrest commonly
Sensory Mx Motor Mx 10-15 sec
-excruciating pain - facial twitching, grimacing b. Partial – initiated on the specific part of the brain
Mgt.DOC: Carbamazepine (Tegretol) – N- 5-12 mcg/ml and it may spread
Surgery: Facial Rhizotomy – electrode inserted face to
the skull (base) via foramen ovale, heat current applied Type:
to CN5 to partially destroy it & to resolve Mx • Simplex – patient conscious
Health teaching: Avoid triggers • Complex – patient unconscious
Diagnostic pro.:
2. Bell’s Palsy a. EEG – use H2O soluble adhesive gel
Cranial nerve #7 prep: -avoid anticonvulsant
✓ Compress or inflammation due to autoimmune ✓ hair shampoo- to attach electrodes easily
response or infection Herpes simplex/virus ✓ avoid stimulants (caffeine)
Sensory ✓ no sleep the night prior to a sleep EEG (test
✓Unilateral facial paralysis with/without a stressor)
Motor ✓ Not painful – inform pt, dec anxiety
✓facial drooping Phases of seizure
✓inability to close the eyelids a. Aura
complete • flashes of lights
• smell of a burning wire
• metallic taste ✓ Kernig’s sign (Hamstring muscle strain) –
b. Unconscious - secretions patient lie flat flex the hip and extend the Knee
c. Tonic- stiffening – shape of arch common there will be rigidity.
d. Clonic – jerking WOF:
e. Postictal – sleep phase ✓ Photophobia
✓ Secretions ✓ Seizure episode
Interventions ✓ N/V (projectile)
1. Stay calm Mgt.
2. Mark the start time – assess seizure duration ✓ Antibiotic
3. If the patient is standing, lay the patient on the ✓ Dexamethasone (Corticosteroid)
ground (rush to apply pillows) ✓ Antipyretic
4. If lying on the side - to prevent aspiration suction ✓ Anticonvulsant
the secretions as needed, then provide O2. If side- ✓ Anti-emetics
lying is contraindicated just turn the head to the 3. MIGRAINE
side, PRIO - Airway ✓ Serotonin= mood, appetite, pain, sleep MAPS
5. Loosen the tight clothing and remove unnecessary Serotonin due to stress and tyramine rich foods
materials near the patient (chocolate), fermented foods, beer, wine, sausages,
6. Observe for the duration except cottage cheese
✓ Do not put anything in the patient’s mouth
✓ Do not promote abrupt temperature change, (estrogen imbalance)
just TSB ✓ Vasodilation – ex. “nitrates”- S/E headache
✓ Side rails up Phases: PAAP
7. Monitor V/S and level of LOC a. Prodromal phase – days before the attack
DOC: Diazepam (Valium) – emergency drug -Mx - sensitivity to light, sound etc.
✓ (+) disorder of status epilepticus - Excessive yawning, thirst, cravings for
Maintenance drug food, sleep, irritability, loss of focus
Barbiturates – (CNS depressants) A/E – bone b. Aura phase – min to hours before the attack
marrow depression - Mx – visual disturbance, ex. Flashes of light
✓ CBC monitoring c. Attack phase – pain phase
Dilantin (Phenytoin) – S/E- gingival hyperplasia - Mx- throbbing pulsating, N/V
✓ 10-20 mcg/ml- therapeutic level - common- unilateral pain (excruciating)
Valproic acid (Depakene)- 50-100 mcg/ml - do not lean forward or look down, it will
therapeutic level aggravate.
Lamictal or Phenobarbital d. Post-dromal days after the attack
2. MENINGITIS – fatigue, sensitivity to light, lethargy
✓ Meninges – covering of the brain DOC: - vasoconstrictor
✓ Causes: Migranal
✓ Bacteria (streptococcus pneumonia or Neisseria Frova - Serotonin agonist (mimics the effect)
meningitidis), deadly even an hour < 20 y.o. Increase Intracranial Pressure
✓ Virus- entero/coxsackie virus- common <5 y.o. Cause: Trauma, Tumor, Infection
✓ Fungal – cryptococcal meningitis ✓ Edema O2 Hypoxia
Mx: ✓ CSF displacement
✓ Fever ✓ Brain stem herniation respiratory
✓ Rigidity/nuchal rigid depression RR
✓ Brudzinski’s sign (back of neck)– patient lie flat, V/S - BP (Rock ‘n Roll sign)
flex the neck (outcome hips and neck flexion) RR
HR
Temp
Widened pulse pressure CEREBROVASCULAR ACCIDENT “STROKE”
Normal: 5-15 mmHg Thrombus- 1° culprit
Acceptable: 15 – 20 mmHg
Intervene: >20 mmHg O2 in pressure of blood vessels
Mgt. O2
Semi- fowlers hypoxia ruptured
Dexamethasone (Corticosteroid)
Mannitol – ideal (fast, bolus because it crystalize) Ischemic stroke Hemorrhagic stroke
Surgery – craniotomy (ventriculostomy tube) Mgt:
✓ JP (Jackson Pratt -ideally given - Tranexamic acid (hemostan)
drain)-do not within 3-6 hours - Aminocaproic acid (Amicar)
apply pressure Consider when pt last Position- High level of head/
seen well last resort fowlers
Craniotomy • Thrombolytics Avoid neck flexion –
Transsphenoidal • Fibrinolytics impede drainage
Hypophysectomy- suture line • TPA (tissue
between the upper gum and plasminogen activator)
upper lip, ideal position semi- -Anticoagulants
fowlers - if you don’t know the onset
Supratentorial (cerebrum) – post semi-fowlers. - more than 6 hours
Suture is in the hairline - WOF bleeding
Infratentorial (cerebellum) – suture is at the base of Rule of 10
the skull, post flat on bed HEPARIN PTT
WARFARIN PT
Basilar Skull Fracture- Trauma leads to leakage of Position- low level of head/low
blood and CSF, Sign: HALO fowlers, flat-last resort
Battle’s sign or Mastoid ecchymosis - CSF S/Sx
leakage or blood in the ear ✓ Slurred speech
Racoon’s eye/periorbital hematoma- blood ✓ Hemiparesis- weakness
leakage in the eyes ✓ Hemiplegia - paralysis
✓ Aphasia
✓ Facial asymmetry
Otorrhea- CSF leakage in the ear Aphasia

Epistaxis – nose bleed Scene 1
Rhinorrhea – leakage of CSF in the nose “Taaaa….kkkkkeeeeee…..?”
Hematoma ✓ Expressive
Mgt- surgery and evacuation of hematoma ✓ Brain affected- Broca’s area (frontal)
Epidural Subdural ✓ Mgt. Pen and paper, pictures
Above dura Below dura Scene 2 “ When? Easy for my river runs black boxes
-Artery - Vein whizzle abatta when bobbles come!!!”
-rapid blood accumulation - less rapid ✓ Receptive
-rapid in LOC - less rapid ✓ Word salad
✓ Brain affected – Wernicke’s area (temporal)
✓ Mgt. Talk slow and use action
Scene 3- both are affected – Global aphasia
GLASGOW COMA SCALE reason why flushing, diaphoresis, headache, nasal
Eye opening Verbal Motor stuffiness & slow HR (Mx above the lesion site-most
response Response Response
4 – Spontaneous 5 – Oriented 6 – Obeys
common T6) (below the lesion – cold and clammy skin)
(open then remain (time, place, person- commands Intervention: fowlers position- drainage
open) 3 spheres) 5 – Localize’s pain ✓ Notify the dr
3 – To verbal 4 – Confused (inflict pain in the
stimuli (1 sphere affected) localize towards ✓ Monitor v/s & LOC
(open-close) 3 – Inappropriate central area)
2 – To pain words 4 – Withdraws from SENSORY DISORDERS
(open-close with 2 - Incoherent pain (inflicts pain to
stimuli/sternal rub) 1 - None distal area, patient
1 – None withdraw)
3 – Flexion to pain
or decorticate
(deCURLticate)
2 – Extension to pain
or decerebrate
1 – None
Scoring:
14 – 15 = conscious
11 -13 = Lethargic
8 – 10 = Stupor
4 – 7 = Coma
3 = Deep coma = REPORT!!! usually every hour
8 = intubate
* if with mech. vent just document. 1. Cataract
✓ Lens – with protein and H2O
SPINAL CORD INJURY ✓ Cause: Aging
✓ The higher the injury the greater the injury
Agglutination (protein clog together)
C1 – C4 = Diaphragm (diaForm)
C5 – T4 = T (Arms)T5 – T6 = Blurring of vision, blindness, (-) red reflex,
Chest (6hest) opacity of the lens
T7- T12 = Abdomen (1.2 –abd)
L1- L5 = “L” legs ✓ Intervention:
S1 – S3 = 3 letters GIT & GUT ✓ ICCE (Intracapsular Cataract Extraction)
S4 –S5 = Sex organs ✓ lens including elastic capsule removed
Coccyx = sensation of coccyx ✓ ECCE (Extracapsular Cataract Extraction)
✓ Only lens is removed
✓ Phacoemulsification
AUTONOMIC DYSREFLEXIA ✓ All give mydriasis, ATB (antibiotic),
- life-threatening Anticholinergic (Atropine), neo-
- T6 synephrine -- SNS
- cause = noxious stimuli, so just remove the stimuli ✓ All there’s a lens replacement
- ex. Full bladder, fecal evacuation, kinks in cath., pressure
WOF: Pain & restlessness post-op is reportable
ulcer, tight clothing, constipation
✓ Apply patches (both)
- response of the body
✓ Side-lying on
a. Sudden surge of sympathetic response – wide
unaffected area
vasoconstriction Mx. Paroxysmal HTN (sudden)
b. Activate vagal response (PNS)
vasodilation
2. Retinal detachment EYEDROPS
Usually cause by trauma 1. Sitting, head tilted back/supine
2. Expose the lower conjunctiva
Tear 3. Hold and stabilize the dropper at the forehead
4. Ask the patient to look up, instill # of drops
Blood accumulation 5. Close eyes gently for 1-2 min
6. Occlude lacrimal duct to prevent systemic absorption
Flashes of light Od - right eye (going to right)
O S - left
Floaters (small flecks or threads) OÜ – both
Mx: Ear disorders
Darkening of your peripheral (side) vision Otosclerosis Meniere’s dse
Tx: Cause Hereditary Unknown/infection
Affected part Stapes (bone) Inner Ear
1. Scleral buckling- apply elastic sponge site tear to Type of Conductive Sensory Neural
apply pressure hearing loss
2. Laser photocoagulation- repair tear cautery S/Sx Vertigo Vertigo
Tinnitus Tinnitus
Irritability Aural fullness (just like
*post affected side, 1 patch only Dizziness diving then ear pressure)
Mgt Stapedectomy Surgery:
3. Glaucoma labyrinthectomy
Med.
- intraocular pressure (Normal 10-20)
-Meclinizine/bonamine/
antivert
Obstruction of the aqueous in humor -betahistine (serc)
- Na Diet
lens production
EARDROPS
1. Side-lying on unaffected area
Closed angle glaucoma Open angle
2. Straighten the ear canal
Pain No pain ✓ >3 pull the pinna up
and back
Mx. Both ✓ <3 pull the pinna
Halo down and back
Peripheral vision loss 3. Hold dropper
Blurring of vision 4. Instill in ear canal & allow it to flow inside
Blindness 5. Place cotton ball above the ear flap
Mgt. 6. Massage and remain still
Iridectoy miOtic:
Diamox Pilocarpel
-diuresis -- IOP
(both) - miotic drug
Timolol
- drug production
of aqueous humor
-given LIFETIME Ad - right ear (going to right)
-Timoptic A S - left
AÜ – both
ENDOCRINE SYSTEM PHYSIOLOGY
Hypothalamus
✓ Posterior pituitary
ANATOMY:
✓ Oxytocin – stimulates uterine contractions,
OA
milk ejection during lactation
✓ ADH – reabsorb H2O only
-controls the excretion of H2O by the
kidneys
✓ Anterior pituitary
✓ Growth hormone – stimulates growth at night
✓ Ass. with Dawn phenomenon
✓ Prolactin – stimulates development of
mammary gland and secretion of milk
1. Pineal glands- melatonin (sleep hormone)
✓ Melanocyte Stimulating hormone – stimulates
Melatonin – hypersomnia
production of melanin
Melatonin - insomnia
✓ TSH Thyroid T3, T4, Calcitonin
✓ Sleep-wake cycle or circadian rhythm
✓ ACTH Adrenal Cortex Glucocorticoid
2. Hypothalamus – big boss, link to your CNS to
and Mineralocorticoid
endocrine system
✓ FSH and LH gonads
3. Pituitary
FSH – stimulates gamete (ova and sperm)
a. Anterior
production by gonads
b. Posterior
LH- stimulates sex hormone (estrogen and
4. Thyroid- if you see this word think of metabolism
androgen) production
5. Parathyroid – Ca+ metabolism, release of PTH
transfer Ca+ from bone to blood
DIAGNOSTIC TEST:
✓ Ca+ = PTH – spasm, tetany, tingling
1. Stimulation:
✓ Ca+ = PTH – weakness
H2O deprivation test
6 Thymus – responsible for immune system, for T-
✓ Test for DI
cell maturation
✓ Avoid fluids 4-8 hours
7 Adrenal
✓ Induce dehydration BV = BP
a. Adrenal cortex
✓ Normal response = posterior pituitary gland
Glucocorticoid (cortisol) steroid
ADH H2O reabsorption oliguria
Stress hormone
concentrated urine USG and urine
✓ Cause blood glucose immune sys.
osmolarity
✓ CARBO and Fat metabolism
✓ Abnormal - posterior pituitary gland ADH
Steroid Treatment
H2O reabsorption polyuria USG and
✓ Normally no cortisol release by the
urine osmolarity
body
Aldosterone (mineralocorticoid)
2. Suppression test (dexamethasone-steroid)
✓ Na+ and H2O reabsorption
✓ Test for Cushing’s
b. Adrenal medulla – tumor problem
1. Fasting 10-12 hours
Catecholamines
2. At night give dexamethasone 1mg p.o.
Epinephrine cardiac output
3. Get baseline cortisol levels in the morning
Norepinephrine BP
4. Get cortisol level
8 Pancreas
with Cushing glucose and cortisol
9 Ovaries
Normal cortisol level < 5 ug/dl
10 Testes
Abn > 10 ug/dl
PATHOLOGY B. ANTERIOR PITUITARY GLAND DISORDERS
A. POSTERIOR PITUITARY GLAND DISORDER 1. HYPOPITUITARISM
1. DIABETES INSIPIDUS (DI) Types:
Problem: ADH H2O reab H2O a. Sheehan’s – post-partum pituitary
wasting Polyuria BV BP leads necrosis (due to severe blood loss)
to Cardiac Output Volume b. Simmonds’s dse – panhypopituitarism
= diluted urine: USG - < 0.010 (all) posterior and anterior
Urine output c. Dwarfism – common primordial, GH
WOF: Shock – polyuria leads to dehydration Posterior - ADH - DI
leads to weight loss leads to Polydipsia Anterior - LH and FSH, loss of libido or
= hemoconcentration - serum osmolarity oligomenorrhea or amenorrhea, infertility,
Meds: Prevent voiding delayed puberty
WOF: fluid overload edema = BP ACTH – Addison’s
Potent vasoconstrictor TSH – hypothyroidism - GH – growth
Desmopressin (DDAVP, Stimate) retardation/ central obesity
S/E – runny nose; intranasal – alternate Meds: lifelong hormone therapy
nostrils to prevent irritation except Somatrim, Somatropin – give until
Lypressin (Diapid) puberty/desired height reach; GH substitute
Vasopressin (Pitressin) – bedtime: prevent nocturia/
sleep disturbance 2. HYPERPITUITARISM
Nursing Intervention: OFI Tumor/pituitary adenoma/pituitary
hyperplasia
2. SIADH Posterior - ADH - SIADH
ADH H2O reab Oliguria BV leads Anterior - LH AND FSH precautious
to BP CO Hypervolemia puberty (early onset)
= urine concentrated: USG and urine output ACTH - Cushing’s
= hemodilution - serum osmolarity TSH – hyperthyroidism
WOF: cerebral edema ICP = LOC GH – before epiphyseal closure,
Nrsg Int: Restrict OFI Gigantism –height 8ft
after epiphyseal closure,
Oliguria leads to fluid overload weight gain Acromegaly/size - bone structure,
Na+ expected Skull
Meds: induce voiding Hand and feet size
Demeclocycline (Declomycin) – antibiotic cause Jaw is protruding
it has diuresis effect Acromegaly complication
IV hypertonic saline (3%) – prevent cerebral Skull
edema
Diuretics – K+ wasting to conserve Na+ Damage to optic nerve (compression & ICP)
BFHM Common problem:
X a. Bitemporal hemianopsia – loss of
DI SIADH peripheral vision outer half of L&R
H2O H2O
BP BP
Cardiac output Cardiac output
polyuria oliguria
Na+ Na+
Hct Hct
b. ICP – hypertension & Bradypnea
Mgt: Semi-fowlers
Meds: Bromocriptine (Parlodel)-adenoma Thyroid hormone (1° hormone)

Octreotide (Sandostatin)- prevent GH pro. Primary
Surgery: best Opposite
Hypophysectomy – removal of pituitary Secondary
gland Equal
a. Craniotomy 2° problem 1° problem
b. Transsphenoidal Surgery – preferable Anterior pit ( anterior pit. not damage)
Instrument inserted in the upper Thyroid = TSH Thyroid = TH
gingival mucosa between the
upper lip and gum TH TSH
Complication:
• CSF leak – fluid in the nose Anterior pit
WOF: rhinorrhea Thyroid = TSH Thyroid = TH
✓ get a 4 x4 sterile gauge and
get a sample of fluid for test TH TSH
(+) glucose = CSF leak 3. Calcitonin (Ca+ metabolism)
✓ yellow ring formation (HALO Ca+ from blood to bones
sign) = (+) CSF leak If thyroidectomy
• Disturbance of the operative site
✓ Avoid bending, straining, Later: osteoporosis
Valsalva maneuver, vigorous
coughing, usage of straw, HYPOTHYROIDISM= think of slow metabolism
toothbrush = 2 weeks AKA: Myxedema
✓ Infrequent gentle flossing Cretinism (pedia)
✓ Avoid mouthwash Problem:
✓ Toothettes 1. Hashimoto’s Dse (autoimmune)
✓ Gentle gargle NSS 2. Diet: iodine deficiency
• ICP – position semi-fowlers post procedure and 3. Complication of procedure - Thyroidectomy
provide non-stimulating 4. RAI 131 (radiation therapy)
• Hypopituitarism Manifestations:
WOF: DI Acne
Addison’s Amenorrhea (rare) *menorrhagia (most)
Hypothyroidism Bradycardia
Mgt: lifelong hormonal replacement therapy BP
except GH Constipation
*Subjective data -assess 1st Cold intolerance
Dry skin
C. THYROID GLAND DISORDERS Dull mental process
Thyroid hormones Temp: cool
1. Thyroxine (T4) Alert
2. Triiodothyronine (T3) Metabolism = cholesterol, wt gain
Feedback Mechanism Sweating
Anterior pituitary (2° gland) Risk: Atherosclerosis
Complication: Stress, Infection, Sedative
TSH (2° hormone)
Myxedema Coma
Thyroid gland (1° gland)
Severely TH WOF: thyroidectomy- so lifelong TH subs
Surgery: Thyroidectomy
Exaggerated lethargy- Sign of myxedema coma Pre-op: teach deep breathing exercise and
Priority: airway, O2 coughing technique – hastens healing/recovery
Med: Levothyroxine (levothroid, levoxyl, synthroid IV- Adm Lugol’s solution
best) and Liothyronine = hormone replacement AM Post-op – No to hyperextension of the neck
with empty stomach Position semi-fowlers
WOF-report: fever, chest pain (cause of lactic acid) Interventions: bleeding precautions
Dx: Activity intolerance r/t fatigue If bleeding: Trache set at bed side
Alert Dr “?” __ never
*Both does not affect GUT/GIT = / Thy. STOP meds causes
Expected: mild hoarseness of the voice
HYPERTHYROIDISM = metabolism Mexedema coma WOF:
AKA: Graves dse or Thyrotoxicosis leading to death not Thyroidism
Manifestations: unless specified Thyroid storm
Heat intolerance, skinny, hyper, hot Hemorrhage
*Exophthalmos (hallmark sign) –use sunglasses Laryngeal nerve damage – high pitch stridor
Diarrhea Hypocalcemia
Diaphoresis Accidental removal of the Parathyroid
BP, Temp: warm Osteoporosis
HR
Alert D. PARATHYROID GLAND DISORDERS
Metabolism, sweating,*mood swing HYPOPARATHYROIDISM
Amenorrhea*(most)
Total_Tenaty
Complication: PTH
Subtotal_thyroid Storm
a. Stress, Trauma, Infection
b. *Thyroidectomy – leak of thyroid hormone Ca in blood
Important to check the BP Hyperphosphatemia >4
These complications lead to thyroid storm – Hypocalcemia muscle spasm, S/Sx Ca+
severely TH exage Sx of delirium,
fever, restlessness, coma Bradydysrhythmia Comp.
Priority: airway, dosage of meds Slow and irregular heart rate tetany
Treatment: Paresthesia
Put PTU or Propylthiouracil WOF: Agranulocytosis Laryngospasm
Thyroid Methimazole (Tapazole) WBC – report!!! (DOB & dif. to speak)
Under fever, sore throat Meds: Calcium gluconate IV
Beta-adrenegic blocker Ca+ supp-dairy products, salmon,sardines
SSKI, Lugol’s Solution (Strong iodine solution) Vit D supp
Cause of iodine give using straw, dilute with
orange juice, milk or H2O HYPERPARATHYROIDISM
Pre-op med for thyroidectomy to vascularity
of thyroid gland hemorrhage PTH
RAI (131) – radiation therapy – pt needs to be alone
for 24 hours, urine risk for nurses flush 3x or call Ca in blood
hazmat team pH
Radioactive (destroys thyroid) Hypercalcemia weakness
Internal and unsealed radiation – excreta: flush Comp. = renal calculi
toilet 2x, no to pregnant/breast feeding Tachydysrhythmia Osteoporosis
Meds: TH substitute (fast and irregular)
Ca+ supplement Meds: Diuretics – K+ wasting – it will also
Excrete Ca+ BFHM Moon face shape
X Supraclavicular fat fads
Calcitonin (Calcimar, Miacalcin)-nasal Truncal obesity
spray = Ca+ bones & Ca+ in the blood Pendulum abdomen
Phosphate IV= Ph in the blood Ca+ Thin extremities
E. ADRENAL GLAND DISORDERS Thin skin
*hyperthyroidism – leads to heart failure if not Treated Acne, hirsutism
• ADDISON’S DISEASE Purple stretch mark /
“Adrenal insufficiency” striae, ecchymosis
WOF= K+ Bruises, purpura,
H+ acid = metabolic acidosis petechiae
Salt, Sugar and Sex Immune system
With the 3S you can
Problem: cortisol already answer the
correct S/Sx Risk for infection
Hypoglycemia Salt, Sugar, Sex cortisol = hyperglycemia
Diet: CARBO Some: Ca+ absorption
Hallmark sign: bronze skin K+
Hyperpigmentation H+ acid = metabolic Alkalosis
Bronze pigmentation Aldosterone Na+ & H2O
Mgt: Steroids (risk for infection)-cortisol
Florinef- replace Aldosterone Oliguria FVE
WOF: K+
BP & BV weight gain
Aldosterone Hemodilution- serum osmolarity
Diet: no sweets
diet: Na Na+ and H2O FVD Na/ maintain 2g/day
maintain 2g/day ✓ K+ rich foods
no Na+ substitute polyuria Weight loss ✓ Salt substitute
no K+ rich foods hemoconcentration Mgt. Hypophysectomy – pituitary
BV & BP serum osmolarity Adrenalectomy – Adrenal life long
Hormonal rep.
Comp. Cardiac Output= Shock CONN’S SYNDROME
Addisonian Crisis Hyperaldosteronism
BP HR RR, pain, Sign of LOC Problem: Aldosterone Na+ BP
Mgt: Lifelong hormone replacement therapy H2O: initial retention
K+ & H+ acid = metabolic Alkalosis
Specific: K+ - induce hypokalemic - nephropathy
Kidney cannot concentrate urine
Polyuriaftr
weight loss, polydipsia Dehydration

Mgt.: Diuretics – K+ sparing
• CUSHING’S DISEASE o DOC: SAT
Cushingoid appearance Antihypertensive
Thinning of hair K+ supp
Buffalo hump Adrenalectomy- lifelong hormone rep
PHEOCHROMOCYTOMA Mgt: insulin
Adrenal medulla tumor – WOF- hypertensive crisis
Treatment:
180/120 mmHg Type 1_DIE_diet, INSULIN, exercise
Norepinephrine and epinephrine Type 2_DOA_DIET, OHA, activity
SNS hyperactive TYPE 11

BP Insulin resistant glycemia
HR
glycemia Weight gain: “some call starvation”
Intra-abdominal pressure = no abd palpation Same S/Sx type 1
Diaphoresis no bend, straining Mgt: insulin, yes to OHA only for type 2
Headache
Mgt: Antihypertensive: Na nitroprusside- control GESTATIONAL DIABETES
Bp if pheo is the cause Placenta: HPL inhibits maternal insulin pro.
Phentolamine ✓ Diet
Surgery: Adrenal medulla resection of tumor ✓ Insulin
WOF: Leak of catecholamines ✓ Avoid OHA
-hypertensive crisis post-op
Bilateral adrenalectomy Diagnostic test:
Removed 1. Fasting blood glucose – fast 10-12 hours,
a. A. Cortex – no cortisol and no aldosterone= BP 60-100, 70-100
b. A. Medulla – no epi and norepi
2. Oral glucose tolerance test common to preg to
Cardiac output BP Fasting baseline: 70-100 mg/dL assess GDM:
WOF: shock/ Addisonian crisis 30-min sample: 110-170 mg/dL fast 10-12 hours
Post 24° post op bilateral- prevent hypotension 60-min sample: 120-170 mg/dL
90-min sample: 100-140 mg/dL
DIABETES 120-min sample: 70-120 mg/dL
TYPE 1:
Auto destruction of beta cells a. Get the baseline blood glucose
No insulin b. Oral glucose concentrate
Hyperglycemia c. Get blood glucose after
cell starvation – polyphagia 3.Capillary glucose monitoring – random bl. sugar
weight loss Type 1_insulin dependent, Regardless of the meal time
weakness juvenile onset, ketotic 4.Glycosylated hemoglobin or HbA1C
filtered by kidneys Type 2_non-insulin dep, adult Normal: 3.5-6 %
onset, non-ketotic
renal threshold Good diabetic control: 7.5 % or lower
glycosuria triggers osmosis leads to Fair diabetic control: 7.6% -8.9%
polyuria (DHN) then polydipsia Poor diabetic control:9% or higher
blood viscosity leads to sluggish blood flow - Most reliable test
- drug compliance
poor blood circulation - measure the amount of glucose inside RBC
last 2-3 months
infection slow wound healing DIABETES MELLITUS (risk factor)- modifiable
cholesterol – diet
BP
Most significant RF - Obesity – more fatty tissue more
resistant to insulin
Non-modifiable Brain barrier
> 45 y.o.
Family history Altered LOC
Gestational DM – macrosomia baby
▪ Common African- Americans Coma
Inlets of langerhans 3. HHNS – Type 2
1. Alpha cells – glucagon = blood glucose lead to severe hypoglycemia 600-1200
2. Beta cells- insulin = blood glucose
blurring of vision- common among 3 comp
ACUTE COMP. OF DM
happens suddenly Dehydration
1. Hypoglycemia cause of food or exercise
Overdose of OHA/insulin K+, shock, seizure
Stages: Mgt.: DKA and HHNS
a. Mild – 60-40 mg/dL triggers epi -regular insulin IV
leads to diaphoresis, palpitations, nervousness, -fluid replacement, isotonic
numbness, hunger leads to inc. HR leads to tremors CHRONIC COMP. OF DM
Mgt. Foods- 10-15 g CHO Macrovascular
-b. Moderate- 40-20 Diabetic foot MI/heart attack
- CNS sx CVA
- Headache Microvascular
Sx like a
- Slurred speech DRUNK person
- Blurring of vision Retinopathy
- Dizziness
- Drowsiness Nephropathy
- Double vision Sensation/numbness ESRD
- Irritability & inability to focus Foot care:
-Mgt: same Food Avoid – cross legs
-c. Severe: < 20 Heat pads (sore feet)
- patient not conscious Lotion in between toes
- seizures Ill-fitting shoes
- Mgt.: glucagon Half size larger (cause blister)
D50W ✓ Fit snugly (shoes at pm)
2. DKA- type 1 no diaphoresis ✓ Cut nails- straight across, NO angles
No insulin severe hyperglycemia 300-800 ✓ Inspect feet & shoes daily
✓ Cotton socks
Dehydration K, shock, seizure Mgt.
Blurring of vision 1. Diet - fiber complex CHO no bacon = fats
Severe cell starvation Exchanges Sample Lunch Sample Lunch Sample Lunch
#1 #2 #3
DKA & 2 starch 2 slices (CHO) Hamburger bun 1 cup cooked
Fat metabolism HHNS_DHN pasta
3 meats 2oz sliced 3 oz lean beef 3 oz boiled
turkey(CHON) patty shrimp
Ketones fatty acids metabolic acidosis & 1 oz low fat
Compensate Kussmaul’s cheese
*Fruity / acetone Nausea breathing 1 Lettuce, tomato Green salad ½ cup plum
vegetable Onion tomatoes
Odor breath Vomiting 1 fat 1 tsp mayonnaise 1 tbsp salad 1 tsp olive oil
Abd cramps lead to respi.alk. dressing
1 fruit 1 medium apple 1 ¼ cup 1 ¼ cup fresh
Can cross blood watermelon strawberries
2. Exercise - before, during and after walking inform Dr. Complications:
✓ Capillary blood glucose 1. Dawn phenomenon- results from a nocturnal release
If CBG > 200 & ketones in urine (green-ketos tix) of growth hormone which may cause blood glucose
No exercise to begin to rise at around 3 am
Before and after – eat snack treat with evening dose of immediate insulin at
Insulin requirement so insulin dosage –exercise around 10 pm
4. Insulin- Rare in Love 2. Somogyi Phenomenon- rebound phenomenon that
peak hypogly peak snack occurs during the initial period of blood glucose
Rapid “logs” = 1° = 10-15 min before meals control; develops at peak insulin times and during the
Regular “R” = 2-3° = IV clear consistency N night.
Short acting DKA, HHNS Normal or elevated glucose at bedtime then decreases
Intermediate = 6-12° = cloudy N at 2 am to 3 am to hypoglycemic levels and a
“N” lente, NPH subsequent increase occurs at a result of counter
Long Acting = 12-16° =mimics the basal glucose regulatory hormones (GH & catecholamines)
“Ultra” Ultra Lente control Treatment includes decreasing the evening dose of
Very long = 24° =do not mix with other intermediate acting insulin or increasing the bedtime
Lantus/glargine insulin snack.
✓ Room temperature 3. Insulin waning- progressive rise in blood glucose
✓ Inside the ref up to 30 days from bedtime to morning
X Sunlight Always check manufacturer’s expiration date, which is Treatment includes increasing evening dose of
X Freezer only good if the bottle is closed//once opened it expires intermediate insulin or long acting insulin or giving a
30 days! Make sure you write the date_exp/date_open dose of insulin before the evening meal
Mixing: Always clear before cloudy
Test glucose Mixing insulin ORAL HYPOGLYCEMIC AGENTS
Insulin NR_NPH + Regular (air injection) Not an insulin
Eat RN_Regular + NPH (withdraw) No to Type 1
• st
Give insulin 1 before eating No to Gestational - terratogenic
• Sick day rule do not stop insulin continue cause BG SULFONYLUREAS – type 2, stimulate insulin rel.
• Rotate sites or move ½ - 1” to prevent lipodystrophy Avoid alcohol – facial flushing
• Abdomen- preferred sites Acethexamide (Dymelor)
Chlorpropramide (Diabinese)
Common types of Insulin Glimeperide (Amaryl)
Type of insulin Onset Peak Duration Glipizide (Glucotrol)
(hour) (hours) Glyburide (DiaBeta, Micronase)
Rapid-acting
Lispro (humalog) 15 min ½- 1 ½ 4-5 Tolazamide (Tolinase)
Insulin aspart (novolog) 5-10 min 1-3 3-5 Tolbutamine (Orinase)
Short- acting insulin ½ - 1 hour 2-4 5-7
Regular (Humulin R, Novolin R)
Intermediate-Acting NONSULFONYLUREAS – delay the conversion of
NPH (Humulin N, Novolin N) 1-2 hours 6-14 24 CHO into sugar ALL
Lente (Humulin L, Novolin L) 1-3 hours 6-14 24
Long-Acting Alpha glucosidase Inhibitor
Ultralente (Humulin U) 6 hours 18-24 36 Acarbose (Precose) – take this 1st bite of 1st meal
Insulin glargine (Lantus) ------ ------ 24 Miglitol (Glyset)
Premixed Insulin
70%NPH/30regular(Humulin70/30) ½ -1 hr 2-12 18-24 Biguanide
50%NPH/50regular(Humulin50/50) ½ hr 3-5 24 Metformin (Glucophage)-b4 giving check kidney Funx
75%lispro protamine/25% lispro 10-15min 1-6 24
Meglitinide- newest – stimulate insulin release
Nateglinide (Starlix)
Repaglinide (Prandin)
Thiozolidinediones- help manage type 2- insulin IV : Descending Colon
resistance. b4 giving check Liver Funx test V : Sigmoid Colon
Pioglitazone (Actos) VI : Rectum
Rosiglitazone (Avandia) GI is not sterile, so clean technique can be used
Dx Procedure
GASTROINTESTINAL SYSTEM 1. Upper GI
ANATOMY: Esophagus
Mouth- mastication Stomach
CN5- trigeminal nerve Duodenum
Ptyalin starch sugar bolus *prob of pancreas leads to mal-absorption
Esophagus – passageway of bolus 2. Lower GI
Lower esophageal Colon
sphincter or cardiac sphincter
Procedure Contrast Posi- Pre Post Comp
Defective = Disorder (GERD medium tion
or Heartburn) Radiographic
Stomach – digest bolus Upper GI Barium High NPO- 6-8 S/E: Anaphylactic
series swallow: Fow hrs Constipation shock
further turns into Chyme a Chalk- lers Chalk like WOF:
partially digested food like stools, report
mixture NI- inc OFI urticaria,
Parietal cells – produce and fiber – pruritus,
hydrochloric acid *all GI series wheat, oats, facial
o Intrinsic factor- helps absorb Vit. B12 needs rice except flushing,
fluoroscopy white, throat
Brain function help RBC prod. helps the dr beans, peas, swelling
Temporary storage of food see real time bron, sun DOB
images needs dried
o Normal- 30 min-1 hr in the stomach x-ray and tomatoes
*Gastrectomy – leads to Complication- barium and green
Pernicious Anemia or dumping Syndrome leafy veg.
Laxative per
drs order
Small Intestine – 2-4 hrs Lower GI Barium Sim’ 3 days Same for
series enema s (L) prior to upper GI Same for
Nutrients absorption test clear series upper GI
Needs the help of accessory organs for liquid series
absorption. diet
NPO-
1. Liver – produces bile 6-8 hrs
2. Gall bladder- stores bile, pass thru During:c
hange
common bile duct position
3. Pancreas – made up by acinar cells for
produces enzyme juices enema to
quote the
a. Amylase – helps digest CHO colon
b. Trypsin- helps digest CHON Scopy –
direct
c. Lipase – helps digest Fats visualization
Parts: Upper GI: Sim’ NPO 6- Wait for gag Perforation
a. Duodenum @ mouth = s 12 hrs reflex to WOF:
Endoscopy, Local return – Shock
b. Jejunum Gastroscopy, anesthesi Normal 2-4
c. Ileum Duodeno- a– hrs if > 4
scopy lidocaine report
Large intestine / colon spray
H2O absorption and stool formation Medazol
Part I : Cecum am IV-
sedate
II : Ascending Colon the pt,
III : Transverse suppress
gag 6. Hematemesis – Chronic sign, Positioning:
reflex
Atropine
high-fowlers, 2-3 pillows
– dec.
Salivatio B. PEPTIC ULCER DISEASE
n , helps
relax stomach lining has wound (mucosa)
smooth Bleeding is expected
muscle
Lower GI Sim’ NPO 6- Check flatus Perforation WOF: Bleeding so monitor Hgb & Hct
series at s 12 hrs for WOF: Complication: Perforation- severe bleeding,
rectum colonosc Shock boardlike abdomen, shoulder pain (hit phrenic
Colonoscopy opy
Sigmoidosco For nerve)
py – rectum sigmoido Mgt.: GI meds, avoid irritants, CASH and
and sigmoid scpy no
only NPO other foods
cleansing Types:
enema 1. Gastric ulcer-(stomach) acid production
only
GASTROINTESTINAL DISORDERS normal/decrease.
I. UPPER GI DISORDERS Cause: long term (NSAIDS) resulting
A. GASTROESOPHAGEAL REFLUX DISEASE to dec. mucosal lining in the stomach
(GERD)/ HIATAL HERNIA Pain during meals relieve:
Inc CHO
Hallmark sign – heartburn low CHON
vomiting- with HCL & hematemesis
Cause: defective cardiac sphincter so stomach
contents leaks upward (esophagus/chest area) K+ weight loss
Other risk: Aging
Caffeine (cola, coffee, 2. Duodenal ulcer/ Stress
chocolates) Ulcer
Alcohol (Beer) Cause:
Smoking/spicy foods A. Stress alter HCL -inc
Hot foods/high fat foods B. H.pylori (hyperacidity)
-tomatoes (products) & citrus foods – inc. acid
-Dairy products (milk) alkaline – aggravates 2 antibiotics and damage mucosa
acid production to maintain balance & 1 upper GI med (duodenal part)
- Hiatal hernia – cause by obesity, herniated
thorax, weak diaphragm Pain- absent during eating, or pain
Surgical Mgt: Fundoplication (stomach relieve during eating, occurs 2-4 hours
fundus – map esophagus after meals
which strengthen the
sphincter) Overeating
S/Sx:
1. Hydrochloric acid back flow – heartburn Weight gain add further injury
or pyrosis; Mgt. No CASH or other foods At duodenum
that will trigger it & upper GI tract meds (melena)
2. Bloated/fullness – Mgt sips of H2O only, AC- before meals
small frequent meals PC- post sebum/after meals
Medications Action Best time Examples Side-effects
3. N/V – Mgt. Anti-emetics Drs order, Reglan to take
(Metoclopramide), Zoplan (Ondansetron) Antacids -buffers 1-3 hours 1.Al hydroxide -constipation
4. Ptyalism (Inc. Salivation) Mgt. Candies, -neutralizes after (amphogel) (*ala popo)
HCL acid 2.Mg -diarrhea
gums, toothbrushing hydroxide (*mg popo)
5. Dysphagia – Mgt. Thickened food and (milk of
“After With Before Before With” magnesia)
fluid, flex the neck 3.MAALOX –
Combination of WOF: pernicious anemia or dumping
1&2 –preferred -constipation
4.Ca carbonate
syndrome
Dumping Syndrome
H2 receptor with – may “-tidine” Common:
blockers cause GI Cime- Vomiting __right way, fast rate
COMPLICATIONS: Hiatal Hernia __wrong
upset Rani- Anorexia
Famo- Nausea 1. DUMPING SYNDROME way, correct rate
Diarrhea no stomach so no storage
Abdominal
HCL acid cramps
rapid gastric emptying which leads to inc.
Proton-pump before “-prazole” VANDA still bulk of undigested foods in the small
inhibitors 30min-1 hr Ome- intestine (bolus do not turn into chyme) so
Lanso-
Isome- inc. undigested CHO signals the pancreas
Panto- to release insulin leads to hypoglycemia no
-sustained so
do not crush, if
sweets.
suspension- rapid gastric emptying which leads to inc.
mixed with peristalsis can cause diarrhea leads to
apple
juice/sauce DHN, weight loss and fatigue
Avoid hot it S/Sx: bloated, N/V
will precipitate
Sucralfate Coats an before 1 hr Sucralfate Constipation
Early Mx: diaphoresis, dizziness, diarrhea,
-mucosal ulceration (Carafate) and HR
protectors Mgt.
Cytotec Mucosal with Cytotec Can cause
-mucosal lining (Misoprostol) contraction, Small frequent meals, Sips of H2O
protectors no to pregnant Anti- emetics (raglan/zofran)
pt can cause
birth defects
No fiber intake/ cash and dairy products
and premature Inc. OFI
birth GOAL: slow gastric emptying – no CHO/
GASTRIC SURGERIES: CHO, CHON, FAT (slowly digested)
1. GASTRECTOMY: No drinking with meals
TYPES: Do not restrict fluids
a. Total – WOF: pernicious anemia or During meals: low fowlers
dumping syndrome Post meals: supine for 30min to an hr
b. Partial – antrum – end of the stomach with & no ambulation
pyloric sphincter so with gastric remnant 2. PERNICIOUS ANEMIA
No stomach no parietal cells no
intrinsic factor no Vit B12 affect the
brain
Affect the brain = numbness/paralysis
Types: Affect RBC – macrocytic anemia/SOB
b.a Billroth 1 (gastroduodenostomy) Hallmark sign: beefy red tongue
- gastric remnant anastomosis connect to Mgt. B12 IM for lifetime
duodenum Dx: Shillings test - Normal 8-40 %
b.b. Billroth II (bypass gastric surgery/
gastrojejunostomy) – gastric remnant NASOGASTRIC TUBE – post gastric surgery- place
anastomosis connects to jejunum NGT to prevent post op paralytic ileus until bowel tx
WOF: pernicious anemia or dumping has returns –check bowel sounds
syndrome Insertion:
2. VAGOTOMY –removal of vagus nerve – CN10 Position: High-fowler’s
which triggers the parietal cells to produce HCL Measure: tip of the nose to earlobe to xiphoid
Done – post partial gastrectomy process then mark
Assess: Patency of the nares, choose the most patent
Lubricate: KY jelly, Lidocaine gel ADEK absorption – K is for the clotting
Insert: in the nose once reach nasopharynx factor
hyperextend the neck/tilt the neck once reach the Helps detoxify drug taken
oropharynx flex then instruct patient to swallow Diagnostic test: liver biopsy – just a small
(straw) then instruct further till the mark is reach. tissue tests the presence of liver dse/damage or
Check: placement – X-ray – most accurate cancer
Instill air & use stet –check woosing sound Pre-op: assess the prothrombin time – reflect
Gastric content – check gastric pH-1-5 the ability of the patient’s blood to clot
Local anesthesia- used
pH 7 either lungs or small intestine
Feeding/Giving Medications: Position: L side lying/supine with R hand under
Guidelines – enteric, sustained, time released do not head
crush or given thru NGT During: Inhale, exhale hold breath for 5-10 sec
Buccal/sublingual med give as prescribe (puncture area) to prevent puncture of the lungs
Give drugs separately Post-op: R side-lying for 4 hours for pressure to
Position- semi-fowlers prevent bleeding
Assess – bowel sounds (+), try to offer clear liquid if
tolerated notify Dr. then assess placement HEPATITIS
Check- residual volume < 100 mL Normal – liver inflammation
if >100 mL hold= Risk for Aspiration A & E- fecal route standard precaution
Next – flush 30 cc distilled H2O then feed/med B, C, D, F, G – blood borne
WOF: abdominal cramps (+) – HOLD the feeding Laennec’s Hepa – cause is alcohol
until pain subsides then reflush 60 cc distilled H2O Hepatotoxic drugs: TB drugs, birth control pills, NSAIDS,
Types of tube: OHA
1. Salem sump tube (Gastric) Phases:
Double lumen tube 1. Pre-icteric phase – infective phase & precautionary
For continuous & measures strictly enforced
intermittent 2 weeks expose to virus
suctioning Significant liver inflammation- pain RUQ
2. Levin tube Flu-like Sx – fever, loss of appetite, N/V,
Can only handle body malaise
intermittent suctioning Liver function test - ALT & AST
Normal: ALT (Alamine amino transferase)
*If the tube is inserted to machine Or SGPT – men: 10- 55 U/L
WOF- over suctioning of gastric juices Women: 7- 30 U/L
AST (Apartate amino transferase)
H(acid)- metabolic alk. K+ Or SGOT– men: 10- 40 U/L
Women: 9- 25 U/L
II DISORDERS OF THE ACCESSORY ORGANS
A. LIVER (RUQ) 2. Icteric phase – 120 days
Function – produce bile Ass. with RBC lysis
Metabolism of CHON to ammonia
Unconjugated bilirubin –liver biproduct
(waste) urea excreted in urine if not converted bilirubin = Gives N color to the
by the liver reach urine, stool, bile
to the brain leads Conjugated bilirubin -liver biproduct
to hepatic ence- If liver is damage inc. unconjugated serum
phalopathy which deposits in the skin initial= pruritus=
jaundice; if in stools –clay colored; if in Airway obstruction/shock = PRIO
urine – tea-colored Mgt.: vasoconstrictor – vasopressin if w/o rupture
Cholestyramine (icteric phase too) - WOF: v/s BP
acts as a bile acid sequestrant If with rupture – bleeding use Sengstaken
S/E constipation; bile acid is the Blakemore- scissors should be at bedside
component of bilirubin that causes in case emergency deflate; prov pressure
Pruritus prevents further bleeding N 25-40mmHG
A/E: dec. Absorption of ADEK so assess anchors- inflate 100-200 cc of air
signs of bleeding WOF: over suctioning of gastric juices
Diet-Opposite
GOAL: diet CHON CHO with Dumping
H- metabolic alk. & K+
FATS Syndrome Same * vasopressin- DOC when sclerotherapy is CI
3. Post-icteric phase – 6 months with GERD
-* generalized fatigue 2. Ascites
-*cessation of Sx Cause by portal hypertension leads to dec.
-Mgt. Interferon Immunoglobulin oncotic pressure (pulling) & hydrostatic
- not a cure just prevents worsening pressure (pushing) in the peritoneal space
- not lifetime = 3-5x/week SubQ and peritoneum fluids cause dyspnea
Mgt. Diuretics
LIVER CIRRHOSIS Albumin IV- oncotic pressure
Cause: chronic alcoholism Last resort- Paracentesis –relief dyspnea,
Chronic liver dse./ hepatitis or fatty liver leads to drains 2-3 L/H2O,
scarring of the liver so a formation of connective prior: instruct pt to void
tissue called fibrosis for repair. Fibrosis cause best position: sitting/ supine, use local
obstruction of portal vein circulation leads to anesthesia
GOAL: v/s- check BP before, during and
Portal hypertension esophageal varices after; WOF: BP
Neomycin is use for prophylaxis to prevent
X ADEK oncotic ammonia not peritonitis
Risk for bleeding, converted to Albumin IV as ordered= pull back H2O
Petechiae, purpura, ascites waste pro. Urea
Spider angioma so cross blood 3. Hepatic encephalopathy
(micro bleeding) brain barrier Ammonia not converted to urea
(liver cirrhosis)
Hepatic encephalopathy Remains as ammonia
PORTAL HYPERTENSION Cross blood brain barrier

1. Esophageal varices
Early sign HR Blood Brain Barrier Spinal cord
Fibrous (connective tissue)
LOC hyperreflexia
Obstruction of PVC (Blood)
Coma Asterixis (HALLMARK)
Esophageal veins dilated Mgt. Get rid of the
Death ammonia
Rupture Use: Lactulose – osmotic laxative
w/c excrete ammonia with stool
Bleeding Neomycin = remove Normal GI
flora bi product of ammonia
B. GALLBLADDER Mgt. Enzyme juice substitute =effective if with
✓ CHOLELITHIASIS – stone in G.B steatorrhea
Risk factor- 5F’s Pancreatin with meals
Female, Fat, Forty, Fair Pancrealipase
Fertile – inc. estrogen & cholesterol = Somatostatin – treatment for acute pancreatitis
Obstruction in the common bile duct Inhibit release of pancreatin enzyme
injure acinar cells
Bilirubin serum Backflow of bile
(conjugated Na+) enzyme in the pancreas Shock-Mgt fluid rep.
Irritates Isotonic sol.
Deposits in skin (pruritus, jaundice), autodigestion bleeding Cullen’s
Stool (clay-colored), (RUQ) Inflammation sign(umbilical area)
Urine (tea-colored) *(cholecystitis) LUQ pain
diet: fat intake (continuous) w/c
causes R shoulder scapula pain Grey turners
called Boa’s sign Mgt. Demerol (Meperidine) -bleeding in
Best Mgt. cholecystectomy flank areas
Associated with HYPOCALCEMIA = PRIO so give
Open: - abdomen open Close: lap Ca Gluconate WOF: laryngospasm
- takes time to heal - smaller, faster healing Fat- lipolysis – biproduct fatty
- Inc. Risk for infection - insufflate CO2- irritates acids gets Ca+ from blood
phrenic nerve - S/E shoulder form Ca+ soaps
pain
Post-surgery: T-tube stent attached for bile to drain temp. Diagnostic test: ERCP
allow surgical site to heal Endoscopic Retrograde CholangioPancreatography
*Normal bile drain is 300-500 cc for 24 hours Hint: Assess
*meds: Ursodiol= asymptomatic Common bile duct Pancreas Gall bladder
- dissolves gall stones & fat diet Scoped mouth for visualization
CHOLECYSTITIS NPO 6-12 hours
Murphy’s sign- Palpate RUQ then instruct patient to Local anesthesia
inhale then if the patient stop breathing Atropine
momentarily pain (+) Midazolam IV
PRIO – gallbladder problem – pain – Pre- iodine: contrast
DOC Demerol (meperidine) = assess if allergic to shellfish
Avoid: Morphine – cause spasm Post- wait for gag reflex to return 2- 4 hours
sphincter of ODI to the common bile duct = > 4 hours – risk for aspiration
C.PANCREAS Mgt. Removal of gall stones (CBD)
PACREATITIS Dx amylase
- made of acinar cells releases enzyme Lipase serum
- Cause: alcohol injure acinar cells Ca+
Cholelithiasis Surgery: Pancreatic surgery = get rid of dead cells
Enzyme in the small intestine Cholecystectomy
= complication- kidney failure so
Won’t absorb nutrients WOF: shock or oliguria
Malabsorption of Fats, CHO, CHON
Steatorrhea
III.DISORDERS OF THE LOWER GI TRACT Bleeding None Expected: fresh
blood stool-
A. APPENDICITIS hematochezia
Diarrhea 5-6x a day 10-20x a day
Cause: dropped fecalith, seeds Both- prone to DHN

Check Inc. risk colon cancer
Bacteria will proliferate DOC: corticosteroid
Antibiotic – Sulfadiazine
infection Antidiarrheals
Inc OFI
S/Sx. Fever inflammation Diet: fiber
WBC Residue (broiled meat, boiled egg, tea)
Pain (RLQ) radiate to
McBurney’s point DIVERTICULAR DISEASE – only affect colon/large
intestines
Psoas Sign = lie: R thigh Rovsing’s Sign = elicit- *DIVERTICULOSIS
flexion towards the hips palpate the LLQ pain in = outpouching of colons, problem with muscularis
upon extension there will RLQ and serosa
be pain = risk factor:
Fiber/residue
meat
Aging
Trapped fecalith/seed
Asymptomatic
WOF: sudden relief of pain it means – RUPTURE
= Dx: Barium enema
Comp. Peritonitis = significant fever >101°F
Colonoscopy
(38°C); chills, boardlike, rigid abdomen
CT scan
Markle’s sign- (check for peritonitis) you stand on one
= Goal: prevent diverticulitis or comp. Diet inc. fiber and
foot and let the patient drop R heel/toe there will
residue
be jarred landing with localized pain.
*DIVERTICULITIS – inflammation and diarrhea
Prevent rupture = no enema, laxative, fiber rich foods,
= infection – fever and inc. WBC
CASH, heat compress/pads
-Inflammation= pain LLQ Opposite _appendicitis
Avoid: Pain meds – mask
-persistent abdominal cramps
Best Mgt. Appendectomy- general anesthesia, NPO
-diarrhea – so no fiber/residue -Diet
-rupture – comp. Peritonitis further sepsis
B. INFLAMMATORY BOWEL DISEASE
-best mgt. – resection= reg. Stoma
Affect small/large intestine
Stoma- bacterial prophylaxis: neomycin- no infection
Associated with family history
Expected post-op color: beefy red/brick red
Autoimmune- best DOC – corticosteroids
2 weeks – pinkish purple- REPORT!!!
Comparison Crohn’s disease Ulcerative
“regional Colitis
enteritis” TYPES OF OSTOMY
Location affected Small and large Colons -ILEOSTOMY “ileum”
intestine - stool- watery
GI lining Affected All 4 linings – Mucosa only
mucosa, submucosa - Risk for skin breakdown (infection)
Muscularis - Risk for DHN - OFI fiber
Serosa - Drain pouch- continuous
Presenting S/Sx Hallmark: fistula, Ulcer, continuous
skip - ODOR- none
Common site Ileum Rectum - Swim- avoid
-COLOSTOMY “colon” 13. Feed
-Ascending colon- watery 14. Reflush 60 cc
-Transverse colon- semi-mushy
- Descending colon- Mushy GENITOURINARY
- Sigmoid colon – Formed
NURSING
- With odor
- Diet- no gas forming foods to lessen the smell-
Anatomy & Physiology of
yogurt, parsley, beets
the Renal System
- Okay to swim
• Kidney- bean shape,
- Colostomy- sched (water resistance pouch)
brownish red color, locate in a costovertebral angle
- Functional – flatus (bag inflated)
retroperitoneally
COLOSTOMY IRRIGATION PROCEDURE
Functions
Once a day commonly morning
Bone function – synthesis of Vit. D for Ca+
1. Fill container with 500-1000 cc tap H2O
reabsorption
2. Hang it at IV pole 12-18 inches
Bp regulation – RAAS activation if BP
3. Put on clean gloves
Electrolyte – Na+ K+
4. Lubricate then insert 2-4” inside core
Erythropoietin – erythropoiesis – RBC
5. Irrigate: 5-10 min, > 10 min- cause abd cramps
production in response to dec. O2 in the
STOP till pain subside
blood
6. Wait for stool evacuation 30-45 min
Acid base balance – H+ regulation/ acidic
Cleanse! Empty pouch 1/3 full every 4-6 hours
Nitrogenous waste excretion, food rich in
Discard pouch – every 5-7 days
Nitrogen is CHON (protein)
Patient is ready –
a. Patient is looking at the stoma
1 kidney = 1 million nephron- functional unit of
b. Ask about the equipment
the kidney
c. Return demo/active participation
Filtration
Percutaneous Endoscopic Gastrostomy (PEG)
Absorption
Purpose: long term feeding
Secretion
Indicated: ALS, Alzheimer’s
Urination
Order:
Flow and parts – bowman’s capsule; glomerulus –
1. Explain the procedure
initial filtration of blood; GFR (glomerulu filtration
2. Wash hands
rate) test how kidney function, normal 100-120 mL/hr;
3. Provide privacy
loop of henle – descending structure– proximal
4. Assemble the materials
convoluted tubule, reabsorption/secretion, ascending
5. Position: Semi- fowlers
structure – distal convoluted tubule, aldosterone-
6. Wear clean gloves
parathormone (PTH)- goal is to inc. Ca+ level in the
7. Place towel on patient’s abdomen
blood or absorption Ca+; collecting duct; renal
8. Check for signs of infection around the area
parenchyma: adrenal cortex – outer part , adrenal
9. Auscultate bowel sounds
medulla – inner part; renal pelvis – urine collected,
10. Unclamp and aspirate gastric residual vol. < 100
enhouses the renal artery & vein; ureters; urinary
mL and re-instill
bladder – storage , normal 500-1000 mL; Urethra –
11. Pinch the proximal end of feeding tube prevent
female 3-4 inches
air from entering
Acid- base balance
12. Flush 30 cc of distilled H2O
The kidneys will excrete H+ in response to a
decreasing blood pH; they will reabsorb H+ in
response to an increasing blood pH to maintain
homeostasis
pH (acidic) – excrete H+
pH (alkalotic) – reabsorb H+ K+ sparing
SAT
BP REGULATION: THE Renin- Angiotensin- WOF: K+
Aldosterone System (RAAS) For Hyper _DOC: Kayexalate – oral (mix with
= BP – activate RAAS H2O)
1. Liver: Angiotensinogen (plasma protein) Retention enema-retained about 30
Kidney: Renin (enzyme) min for absorption
Angiotensin I (not potent) S/E diarrhea-monitor bowel function
Lung (ACE) *Sodium – blood volume & BP
Angiotensin II (potent)- function binds with A1 Na+ H20 BV BP
receptors of blood vessels – potent vasoconstrictor if FVD
activated - BP Mgt. Canned goods (bouillon)
Stimulate aldosterone production – enhance Na+ Diet: Na+ intake
& H2O blood volume = BP
Na+ H20 BV BP
Expected - BP – edema
Report: =. Brain = Cerebral edema - LOC

ICP – widened pulse pressure
= Heart – CHF signs – non-productive
Mgt. I. ACE inhibitors “-pril” cough, crackles – hypertension, bradycardia,
An hour before meal Bradypnea, temp
Cough, dry and persistent A/E so
Edema, periorbital & facial INTRAVENOUS PYELO GRAM
WOF: K+ Vein kidney visual with dye
Mgt. No salt substitute and K+ rich foods Aka: excretory urography
Prob. B- Ca+, bone prob & BP Can detect presence of
E - K+ stone for suspected
A- metabolic acidosis urolithiasis or
M – Azotemia – accumulation of Nitrogen nephrolithiasis
PHYSIOLOGY OF THE BODY’S ELECTROLYTES Position: Supine
*Potassium = normal 3.5 – 5.1 Injected: Brachial vein
- control muscle, heart and nerves Pre- Assess: check history of allergy and NPO 6-8
- K , DTR (+1) – muscle paralysis hours – can cause metallic taste lead to N/V lead to
ECG = U wave aspiration
St depression Post: Inc OFI and fiber intake – dye causes
T wave inversion/flat constipation if 2-3 days- no stool refer! – Dr’s order
K – early - DTR (+3) – laxative
late muscle weakness - DTR (+) WOF: anaphylactic
ECG = St segment depression shock/rash/urticaria
T wave peak/tented/tall S/Sx DOB, facial flushing,
Interval of PR prolong >.20 sec throat swelling
-Mgt-diuretics DOC: Epinephrine – IM /
K+ wasting – acid partner with H+ IV – dilute
BFHM
For Hypo _DOC: kalium durule (KCl supp)- this RENAL ANGIO GRAPHY
is acidic so given after meal Artery with dye
Give K+ rich foods- PABOWS Detect clot in artery
Position: Supine • Post-renal- Bladder problems/obstructions
Use: iodine-based dye Ex. Renal calculi/ BPH
Insertion: femoral artery Normal urine- approximately 1500 mL
Anesthesia: local Polyuria- > 2500 mL
Pre: Assess history of allergy and check peripheral Oliguria < 400 mL
pulse (popliteal, dorsalis pedis) weak delay/defer, Anuria < 50-100 mL
NPO – 6-8 hours
Post= bleeding straightening of legs at least 6 hours, *Chronic – gradual/irreversible
apply pressure, sand bags- 10-30 mins longer if with - prognosis is poor
anticoagulant/antiplatelets, Stages:
Absent distal pulses REFER!!! • Stage I – Reduced Renal Reserve
DISORDERS OF THE KIDNEY Damage: 75 %
RENAL FAILURE Compensation: 25 %
* Acute – rapid/reversible S/Sx: Asymptomatic
- prognosis is good
- recovery – 2 years • Stage II – Renal Insufficiency
- Types: Damage: 75-90 %
• Pre-renal- all problem is related to heart/circulation S/Sx: BP and edema- RAAS activation due to
Ex. Burn, DHN, Hypovolemia fluid balance disruption that is why there is
Phases: hypertension
a. Oliguric phase- <400mL/day, fluid retention GFR - BUN and Crea = azotemia
leads to inc. BP, edema, . LOC.; prio: K+ Uremic frost- urea crystals- itchy so advice to give
DOC: Kayexalate, Mgt. NO CHON, Carbo, Calamine lotion
NO K+ rich foods, salt substitute, limit fluid Urine odor breath
and Na+ intake 0.5 – 0.8 L/day
• Stage III – End Stage Renal Disease
Urinary fluid retention Damage: 90-100 %
S/Sx: Stage 2 + electrolyte imbalances
GFR < 100 mL/day Ca+ due to Vit D synthesis disruption
Phosphorus (> 4 mg/dL)
BUN & Crea (Azotemia) Mg (>2.5 mg/dL)
Normal: 10-20 0.6-1.2 Mgt. Ca+ supplement (Caltrate plus) – cause it has
Vit D
Urea (cross blood brain barrier) Phosphate Binders (antacids)- ex. ALOH
(aluminum hydroxide), NO- milk of Mg / MgOH, NO
Renal encephalopathy Maalox- combination of Al Mg
Oliguria: < 400 mg/dL - K+ H+ (met acidosis)
S/Sx is LOC Anemia – due to erythropoietin synthesis disruption
b. Diuretic phase – dieresis = >5 L/day Mgt. EPOGEN (erythropoietin)- give SubQ 2-
*initial sign of recovery 3x/wk
Priority: DHN so OFI HEMODIALYSIS
c. Recovery phase – improvement of renal Inside machine has a heparin pump
function – normal BUN & Crea Freq. 3-4x/week
3-4 hours/session
• Intra-renal – kidney problems Artificial kidney – dialysis machine
Ex. Nephrotic syndrome- pts taking nephrotoxic = Diffusion is to remove excess waste
agent such as gentamycin (aminoglycosides) = Osmosis removal of excess H2O
= Filtration
Vascular Access – Vein & artery Most important to remember = check warm temp.
= Internal – done in OR (using the drop light) for rapid clearance or prevent
Permanent abdominal discomfort
a. AV fistula – Tenckhoff catheter = 3-4 cm below or beside
combine artery and umbilicus
vein Normal: clear/pale yellow
o disadvantage Cloudy – infection / peritonitis = boardlike rigidity
– 4-6 weeks healing time of the abdomen – REPORT
o advantage – No Risk of rejection Bloody – check menstruation / newly inserted
b. AV Graft – (PTFE) If it persists for several occasion REPORT!
polytetrafluorethylene tube (plastic) Phases:
o disadvantage –risk of rejection a. Infusion – 5-10 min
o advantage – readily available If cramps – slow the infusion and check if
= External – temporary (done at bedside) solution is warm
encourage exercise using stress ball Dwelling time – 30-45 min
a. AV shunt- temporary using or for > 45 min –cause hypoglycemia
emergency b. Draining time – 10-30 min
b. PTFE - turn the client side to side if SLOW
Check weight before and after, most sensitive KIDNEY TRANSPLANT
indicator Transplanted kidney is at
1L = 1kg iliac fossa
v/s (cause it cause BP) Just below the disease
Auscultate – bruit (swishing sound due to rapid blood kidney
flow) Risk for displacement so
Palpation (+) Thrill NO prolong sleeping or contact sports
AVOID – BP taking on the arm with puncture Risk for acute rejection up to 2 years
Venipuncture Manifestation: fever, flank pain, oliguria, edema, graft
Constrictive Clothing tenderness
Direct pressure DOC: immunosuppressant - Risk of infection for
Encourage – non-vigorous exercise ex. Stress ball lifetime, ex. Steroids, prograft, cyclosporine
Dialysis Disequilibrium Syndrome – new to dialysis (Sandimmune) – can be taken with chocolate, milk or
Neurologic S/Sx orange juice but NO grape fruit juice cause it will
Rapid removal of urea from the blood which potentiate the effect or cause toxicity
triggers osmosis then the H2O will go to the DISORDERS OF THE NEPHRON – destroy
brain which causes cerebral edema, Alt. glomerulus
LOC, ICP = Do not STOP the procedure CHON
right away • NEPHROTIC SYNDROME – autoimmune,
To prevent this slow the infusion or widening of pores of glomerulus (damage of the
gradually introduce the client to dialysis glomerular lining)
PERITONEAL DIALYSIS
Done by the patient Leak of protein
Freq. Daily 7x/wk, 3-
4x/day Leak urine (proteinuria) Albumin
Technique = Sterile Fruity urine
Artificial: Kidney = Oncotic pressure
Peritoneum Liver will produce
Solution: Dialysate fluid ( glucose concentration) lipoprotein which will edematous & BP
2-3L of glucose/fluid bind with fats cause ascites
Hyperlipidemia Hydronephrosis – collection of urine
Mgt. above the obstruction
ean protein so without fat Risk Factor:
imit Na+ intake Chocolate
imit oral fluid intake Okra (lady’s
finger)
Meds. Atorvastatin Sweet
Antihypertensive “ace inhibitor -pril”-best potato/Spinach
Diuretics Diet: Acid-ash diet
Steroids Plums
Infection cause = URTI –group A beta Prunes
hemolytic strep *Cranberries
• NEPHRITIC SYNDROME Corn
Acute glomerulonephritis Cheese
Common causative agent- inflammation of the
glomeruli due to an antigen-antibody reaction • UROLITHIASIS
Sore throat – 2-3 weeks, antigen-antibody Location: ureters
reaction target glomerulus leads to epithelial Component: uric acid crystals
cells and scarring & thickening & increase series Avoid: Beers
of inflammation response. Organ meats
S/Sx. Yeast
No urine/oliguria < 400 ml/day Sardines/Salmon
Edema diet: limit Na+ and H2O Anchovies
Pallor (anemia) Diet: Alkaline-ash diet
Hypervolemia = BP Milk
Reddish brown/cola-colored urine *fruits except plums & cranberries
Increase BUN & Crea = avoid CHON Green leafy vegetables
Tenderness @ flank area
Increase specific gravity TREATMENT
Sore throat FOR RENAL
CALCULI:
DISORDERS OF THE URINARY TRACT Extracorporeal
RENAL CALCULI Shockwave
• NEPHROLITHIASIS Lithotripsy (ESWL)
Location: kidney Simple stones too large to pass through then
Component: Ca+ oxalate ultrasound shock waves crush stones so smaller
Stones pieces pass out of body in urine
Dissection of stones into smaller fragments
Obstruction Eliminated via urine
Position: Supine
Straining Pre: NPO 6-8 hours
IV sedation – midazolam
Hematuria (expected) Post: Monitor for minor bleeding
Priority: Pain Expected S/E bruise in the area
DOC: Meperidine (Demerol) Mgt: OFI
WOF: Oliguria – could indicate complete Comp: Pain – indication that there’s obstruction
obstruction despite smaller fragment
UTI 2° to stasis of urine Monitor: Oliguria, UTI, Hydronephrosis
DISORDERS OF THE BLADDER DOC: Bethanecol – to decrease bladder
• URINARY INCONTINENCE spasm – increase urine output, mimic
Involuntary loss of urine parasympathetic system so increases
Types: GIT and GUT
1. Stress incontinence- intact urethra NEPHROSTOMY TUBE
During coughing, laughing, sneezing For patient with hydronephrosis
2. Urge incontinence – over active bladder “nephro” kidney, “ostomy” opening- minor
Strong urge that cannot be procedure
suppressed NPO for 6-8 hours
Bladder inflammation Local anesthesia used
Parkinson’s Position: side-lying/prone
3. Mixed incontinence (stress and urge) Post- expected – minor
Common in pregnant woman bleeding
4. Overflow incontinence- over distention Check for patency
of the bladder so urine leak (renal PRN for pain med
calculi/BPH)
5. Functional incontinence- functional ILEAL CONDUIT
urinary tract but patient is unable to Anastomosis, the connection of the ureters to the 12
control urination cm loop of ileum
Ex. Patient in late stage Alzheimer’s Stoma
disease, cognitive disorder Color: brick/beefy red
Mgt. Anti-cholinergic – Ditropan to decrease Report: purple/purplish
muscle spasm Frequency drain: 1/3 full or 4-6
Bladder retraining program- behavior hours
medication program; bladder diary; decrease WOF: cause drain continuous – DHN
frequency visit to the toilet and increase interval Skin barrier – prevent skin irritation, avoid
Pelvic Exercise- Kegel’s moisturizing soap/lotion
Acidify urine ( ascorbic acid
) to decrease odor of urine
URINARY TRACT
INFECTIONS – ascending
• URINARY RETENTION- inability to bacteria
completely empty the bladder S/Sx fever, pain during
Catheterization: urination @ flank / suprapubic area/late: hematuria
Urethra: F: 2-3 inches tape @ inner thigh PYELONEPHRITIS
M: 6-10 inches tape @ suprapubic Location: Kidney
or lower abdomen CYSTITIS
Location: Bladder
Mgt. Of the two:
OFI
Avoid stimulants: alcohol, caffeine, beef, spicy
Diet: acid-ash
Cause: Warm sitz bath
1. BPH DOC: Antibiotic – Nitrofurantoin= cause brownish
2. Cystocele – prolapsed uterus urine – so increase OFI with meals
3. Bladder Atony – Mgt. Giving Methenamine- avoid milk cause it works in acidic
urolinergic agent environment
Pyridium- bladder analgesic with meals, may cause Resume sex 7-10 days
red-orange color urine Complication: Perforation
Infection
DISORDERS OF THE MALE REPRODUCTIVE Clot formation = Sx. Bladder
TRACT spasm, Tx. Belladonna alkaloids
• BENIGN PROSTATIC HYPERPLASIA (BPH)
Male 2. CONTINUOUS BLADDER IRRIGATION
*dribbling urine – (CBI)
most common 2-3 L of NSS @ 40 gtts/min
characteristic Inflate catheter with 30 ml of H2O
> 50 y.o. 3 way- inflow, inflation balloon, outflow
Dihydrotestosterone Output – bright red- flow rate
pale/clear - Flow rate
Cellular proliferation of prostate tissue Normal – Pinkish / amber
CBI steps
Obstruction a. Empty 1st if drainage bag
is full of urine
Urine output (frequency & urgency) b. Wash hands
c. Connect the irrigation
Weakened streamed urine solution/bag to the
irrigation tube, priming
Straining & hang on IV pole
d. Wear clean gloves and clean the inflow and
Hematuria (expected) outflow part using antiseptic swab
Dx test: e. Connect the irrigation tube to the inflow part
1. Digital rectal urine f. Connect the drainage tube to the outflow part
2. Normal Size- pea size g. Unclamp the drainage tube 1st
Lab test: Normal h. Unclamp the irrigation tube
(PSA) prostate specific antigen = < 4ng/dl Med Mgt BPH
ESR (check inflammation) = < 15-30 mm/hr Palmetto berries
*PSA > 4 but < 10 = BPH Proscar (finasteride)-prevents conversion of
* > 10 = increase Risk for prostate cancer testosterone
Terazosin (Hytrin)-relaxes smooth muscle UO
WOF: BP = HOLD
Treatment of BPH Pyridium – bladder analgesic
1. TRANSURETHRAL RESECTION OF THE
PROSTATE (TURP) TESTICULAR TORSION
Twisting of scrotum /scrotal sac
Risk: neonates and weight lifters
Blood supply decrease so
decrease O2 flow leads to
Use resectoscope ischemia which is an anaerobic energy supply, leads
Position: lithotomy to increase lactic acid which can cause excruciating
NPO – 6-8 hours pain, edema, swelling
Anesthesia – general DOC for pain is Morphine
Post- continuous bladder irrigation A.K.A If left untreated within 6 hours, it is irreversible
cystoclysis which prevent clot formation up to 3 Elevate scrotum if there’s still pain torsion
days
MALE REPRODUCTIVE DRUGS 2. Diuretic phase
Erectile dysfunction – poor blood supply flow, DM, HTN Client has fluid shifting from interstitial
S/E patients taking antidepressants space to IV leads to increase BP and
Avoid: nitrous oxide drugs cause vasodilation increase kidney perfusion leads to polyuria,
leads to increase blood flow or perfusion such as hemodilution ( Na+ ) so v/s increase and
1. Viagra (Sildenafil) hct so K+ go back to the cell cause of K+
2. Cialis (Tadalafil) PRIO: Infection
3. Levitra (Vandenafil) Mgt. Asepsis
So, this drug can be taken 1° before sex, onset is 3. Recovery phase
30 min, duration is 2-4 hours Prio: wound care
S/E: Facial flushing Mx. Wound debridement
Headache Prio: Pain (Analgesic-morphine 30 min to 1
Mild indigestion hour prior to operation) gather sterile
Notify Dr if erection is more than 4 hours sponges and gloves and collect ample for the
Priapism- painful erection culture & sensitivity test
Prio – ER: Phenylephrine - vasoconstriction Apply silver sulfadiazine cream
Aspiration of blood (syringe) TOTAL BODY SURFACE AREA:
NO NTG – fatal BP THE RULE OF 9’S
Parkland formula for burns:
CARE OF THE CLIENTS WITH BURNS Child:
SEVERITY OF BURNS Head: 18 %
Stage Depth Assessment Front: 18 %
Partial Thickness I Superficial partial Dry, redness Back: 18 %
thickness,
Affects: epidermis Upper extremity: 9 % @
Common – Sunburn Lower extremity: 14 % @
II Deep partial (most Moist, edema,
Perineum for both 1 %
painful) “dermis” blister formation
Full III Full thickness Moist, edematous, Adult
Thickness Affects: SubQ sloughing of skin Head: 9 %
Not painful
IV Deep full thickness Dry, swelling black
Upper Front: 9 %
Affects: muscle, bones or chard Upper Back: 9 %
Not painful Lower Front: 9 %
Stages
Lower Back: 9 %
1. Emergent phase – Shock phase
Upper extremity: 9 % @
Up to 2 days
Thigh: 9 % @
General DHN
Leg: 9 % @
Fluid shifting form IV to interstitial spaces,
edema at burn site leads to decrease BP,
PREVENTION OF SHOCK: Fluid Resuscitation
then decrease kidney perfusion, decrease
BAXTER & PARKLAND METHOD
Urine output, then decrease
4 ml X TBS X wt. (kg)
hemoconcentration, ( HCT) leads to cell
First 8 hours = 50 %
lyses (WOF: K+ cause it move out of the
Next 16 hours = 50 % (25 %, 25 %)
cell) , Na+ trap @ edema/burn site Na+
Computation: adult health nursing
Prio: Fluid Mgt
Situation #1:
Fluid resuscitation = PLR IV
Patients weight = 70 kg
Estimated percentage body burned = 80 %
Fluid requirements first 24 hours = ? ans. 22,400 mL
Fluid requirements, first 8 hours (1/2 of total) = ?
Ans. 11,200 mL
Situation #2: (95%) thin
Patients weight = 60 kg b. Type II- alveolar cells (5%) secrete
Estimated percentage body burned = 45 % surfactant (dec surface tension) and this
Fluid requirements first 24 hours = ? ans. 10,800 mL prevents atelectasis
Fluid requirements, first 8 hours (1/2 of total) = ? c. Macrophages (dust cells) defense
Ans. 5,400 mL 9. Lungs – (-) pressure (sucking effect)
10. Diaphragm – muscle for breathing
RESPIRATORY SYSTEM *DOB – a. Sx use of accessory muscle like the
sternocleidomastoid and trapezius muscle
b. retractions – signify complete to partially
complete obstruction
c. cilia
d. mucous membranes – helps propel foreign
object
Anatomy & Physiology Breathing Nervous System Control

Non-sterile CO2- stimulus to breath
1. Nose Medulla oblongata – main respiratory center
2. Nasal Cavity *wise to position ICP- semi- fowlers
a. Olfactory receptor – responsible for Phrenic nerve – diaphragm
appetite stimulation Function
b. Capillaries – warm the air (humid); 1. Gas Exchange – diffusion
epistaxis cause by trauma, HTN, dry; Mgt. 2. Acid-Base Regulation
lean forward, pressure, cold compression Principle:
(vasoconstriction), notify the Dr. DOC 1. Balance by 2 body system a buffer by Renal
neo-synephrine, nasal packing (“-phrine”- and Respiratory
vasoconstriction); do not blow the nose 2. CO2 (basically acid) + H2O = carbonic acid
3. Pharynx (naso, laryngo, oro) – cough, gag reflex, So, CO2 alveoli = Respiratory Acid
CN IX & CN X CO2 alveoli = Respiratory Alkalosis
4. Epiglottis Metabolic Acidosis – DKA & Chronic
5. Larynx “voice Renal Failure; to balance it should reach its
box” alkalinity so respi can eliminate CO2
Sterile Mgt. Hyperventilate/Kussmaul’s breathing
6. Trachea (wind 3. Immune Function – alveolar macrophage
pipe)
7. Bronchus & ASSESSMENT
bronchioles Lung Volumes & Capacities
Acinus- functional unit of lungs; this is the Tidal Volume (TV) Vol of air inhaled & exhaled
normally @ 300 cc
collective term for bronchioles & alveoli
Inspiratory Reserve Vol (IRV) NORMAL inhalation +
8. Alveoli – has elastic recoil; this is damage in pt MAXIMUM inhalation
with emphysema Expiratory Reserve Vol (ERV) NORMAL exhalation +
MAXIMUM exhalation
Residual Vol (RV) Forever in the lungs. Prevents
3 types of lung collapse
alveoli cells Functional Residual Capacity ERV + TRV. Volume of air left
(FRC) after normal exhalation
a. Type 1- Vital Capacity (VC) IRV + ERV + TV
alveolar Total Lung Capacity TV + IRV + ERV + RV
cells
Rates & Depth of Respiration Remove dentures
Eupnea N rate & depth O2 sat. check (before, during, after)
Bradypnea Dec. rate N depth Normal 95-100%
Tachypnea Inc. rate N depth NPO – 6-8 hours
Hypoventilation Irreg. rate dec. depth Consent
Hyperventilation Inc. rate & depth Have resuscitative equipment
Apnea Cessation of breathing
Observe gag reflex
Cheyne – stokes Inc. rate & depth
Dec apnea Supine before/after procedure – semi –
Biot’s Eupnea (3 breaths) fowlers – prevent laryngeal
Apnea swelling/edema
Normal – bronchial vs vesicular
Bronchovesicular – same inhalation & expiration; heard
over the middle bronchus (scapula)
Vesicular- over the lung fields
Inspiration
Bronchial- heard in manubrium (in sternum & trachea)
Expiration 3. Sputum Culture
Disease Sputum Appearance
Pneumonia Rusty Sputum
Asthma Watery-mucoid
Lung Abscess Foul-smelling
Emphysema Thick-tenacious
TB Early – mucopurulent
Late - hemoptysis
Adventitious - abnormal breath sounds
Crackles – secretions (during inspiration)- just like Collection – early AM
bubbling sounds ✓ Rinse H2O
Wheezing – Expiration; high pitch musical sound signifies ✓ Nebulize- NSS/glycol
airway narrowing; ex. Asthma X Rinse alcohol
Pleural friction rub - inflammation of the pleura because X Antibiotics
it was thickened; heard – peak of inhalation, peak of Acid Fast Bacillus – confirmatory Dx (TB)
exhalation & beginning of inhalation 3 consecutive ams
Parietal – where nerve endings is Arterial Blood Gas (ABGs):
A- Allen’s test
R- Rest 30 min
T- Tight pressure (approximately 5 min)
E- Evaluate pH
R Room air/ O2/ Mech vent
I Ice (to prevent hemolysis place in ice)
Diagnostic Tests: A Avoid suctioning – if suction - falsely low result
1. Chest X-ray (Roentgenogram) - dense – white L Lab within 15 min
ex. P. infiltrates / foreign objects *prepare pre-heparinize syringe to prevent clotting,
Less dense – blacks- air filled lungs for neonate – T syringe with heparin
N.I. 1. Remove jewelries @ chest areas ABG Interpretation – 3.5 easy steps
2. Pregnancy / LMP Step 1: pH
Instruct inhale & hold Step 2: Determine if respiratory or metabolic
2. Bronchoscopy – larynx, bronchus, trachea Step 3: Compensation
visualization Respiratory Diseases & Conditions
Bloody sputum – expected if minimal Atelectasis – lung collapse
If persistent – notify Dr Acute – emboli
Chronic – sputum Serotonin
Initial Sym. - hypoxia, hypoxemia Leukotriene
Restlessness Histamine
Response Sympathetic = inc RR, HR, BP Bradykinin
Mgt. O2- dependent- check Drs order which causes edema (membrane is swollen)
O2 – X flammable (initiate) result to hypoxia even with inc. O2.
✓ combustible Mgt. mech. Vent.
X static electricity (carpet) position is PRONE for lung expansion, not
If with O2 remove 1st before defib all the time though
Sample Q.: Mr. Y, an immediate post-appendectomy
Oxygen therapy patient, is placed on O2 therapy via nonrebreather mask.
Nasal cannula/prongs 1-6 L/min, if more than 6 the pt However, after 15 min. of adm. the pulse oximeter still
will just swallow
Simple Face Mask 7-10 L/min aerosolized meds; indicates that the O2 sat is 88% to 89%. What
(just like nebulizer, ok if with o2 driven complication is most likely?
mist, no bubbling -increase)
a. Aspiration Pneumonia
Partial Rebreather mask 8-12 L/min with reservoir bag;
check CO2 in the mask b. Pulmonary embolism
Nonrebreather mask Check O2 concentration c. Spontaneous tension pneumothorax
2 valves (environment/room air 100 %; compression bag
and O2)
d. ARDS
T-piece- weaning High flow – push O2 to pt
Venturi Mask Most accurate O2 device Acute Respiratory Failure (ARF)
COPD paCO2 > 50 & paO2 < 50
Respiratory muscle disorder (ALS, GBS, MG –
Lobectomy – removal of the lobe, CTT if with fluid common cause of death is respiratory paralysis), if
accumulation diaphragm is damage CO2 is trap and O2 cannot
Same with Sigmoidectomy enter
Lobectomy Severe Chronic disease – Asthma/bronchitis
Unaffected
Pneumonectomy Conditions Causing Respiratory Failure
Affected Affects the flow of blood into the lungs:
Pneumonectomy – removal of the entire lung Pulmonary embolism – blocks the blood
= perform arm exercise 2/3x a day (ROM) to prevent flow and causes lung damage
shoulder ankylosis stiffness Affect the nerves and muscles that control breathing:
= cut phrenic nerve – helps diaphragm rise Muscular dystrophy, ALS (inc CO2-
= fluid will solidify respiratory acid), Spinal cord injuries
✓ Fluid accumulation Affects the areas of the brain that control the breathing:
X CTT Strokes, Drugs/alcohol abuse
Complication of both: Affects the flow of air in and out of the lungs
1. Tracheal deviation COPD, Cystic fibrosis
2. Atelectasis- most common comp. UP Affect gas exchange in the alveoli
3. DVT – comp. DOWN ARDS, Pneumonia
Pain dec. = shallow breathing leads to dec. surfactant
leads to atelectasis Artificial Airways:
Mgt. Deep breathing Nurse job:
Give analgesics ✓ Placement
Splint- put pillow over the incision ✓ Inspection: bilateral lung expansion
✓ Auscultation
Acute Respiratory Distress Syndrome (ARDS) ✓ Sound
injury leads to inc
1. Endotracheal Tube (ET tube) VR-ventilator rate – 20 cpm
Chest x-ray- confirmatory, 1-2 cm from carina High pressure alarm (resistance/obstruction)
✓ 21 days only, if > 21 source of infection Increase secretions
✓ 20-25 mmHg – inflated, OK - pt can’t Bronchospasm
speak Pt is anxious/fights ventilator
If pt can speak it means it is not inflated Low pressure alarm (leak)
if < 20 / leak – causes aspiration Self extubation
if > 25 can result to perforation/fistula no spontaneous breathing
detached
Manually ventilate if you can’t see the cause of alarm
PEEP – for pt. with congestion, dec. CO so dec. BP
Positive
End
Expiratory
Pressure
2. Tracheostomy
CPAP – small like nebulizer
Stoma in trachea, Normal 20-25 mmHg with cuff (outer)
both inhalation and exhalation
Obturator – at bedside to facilitate insertion
for pt with obstructive sleep apnea
Inner cannula – hydrogen
Continuous
peroxide + NSS
Positive
In Use:
Airway
Deflate the cuff
Pressure
Remove inner cannula- to
Flail Chest – pathognomonic sign is paradoxical breathing
expose holes
Cause: multiple rib fracture (trauma, accidents)
Plug
Rib or sternum fracture
Not in Use
Mgt: Allow fracture to
Plug
heal
Inner cannula
Pneumothorax – air in pleural
Inflate the cuff
space
(secure)
CTT upper part
3. Mechanical Ventilation
X-ray shows pitch black cause it is still an
Alarm ON- check machine 1st (temporary lung of pt.)
air without blood vessels
a. Controlled Ventilation – respiration comes
Types:
from the machine
a. Open – stab wound
b. Assist/Control Mode – assistance from the
b. Tension/Valvular - blunt trauma (valve like
machine
structure, Inhale (air is in) Exhale (air trap)
c. Synchronized Intermittent Mandatory
c. Spontaneous – pt. with emphysema
Ventilation – more effort from pt than the
-with air bleb without trauma
machine (T piece attached to O2)
Assessment:
a & b for weaning - FIO2 by 5 every 1 hr
a. Unilateral chest expansion
VR by 1 every 2 hr
b. Diminish breath sounds
8 am FIO2 – 100 %
c. Tracheal deviation to unaffected side
VR – 20 cpm
Mgt: Drain air (upper) – CTT
9 am FIO2 – 95 %
Pleural Effusion – mgt CTT – lower
VR – 20 cpm
Dry cough (secretions is trap)
10 am FIO2 – 90 %
Type of fluid Source of 1°Ass. Disorders
VR - 19
fluid
FIO2- fraction of inspired O2
Room air = 21 % O2
Hydrothorax Water fluid that Cardiovascular dse with high 2. Hospital Acquired P. – usually
diffuses out fr BP, liver or kidney dse
capillaries (hypoproteinemia)
intubated, >48°, Pseudomonas, MRSA
Transudative Leukocytes, Infection, Inflammation, 3. Pneumonia in immunocompromised
plasma proteins Malignancy of pleura Host -AIDS (jiroveci p.), Age (too
Exudative Debris of Pulmonary infections
infection (pus) (pneumonia, lung abscesses, young, elderly), burns/surgery,
infected wound) corticosteroids
Hemothorax Hemorrhage Traumatic injury, Surgery 4. Aspiration
CTT – pleur-evac
Mgt.
✓ Pt can turn
1. Suction – dominant (sterile), non-
✓ Ambulate
dominant (unsterile)
✓ Dislodge – non-porous
2. Inc. O2- 100 %
X Clamping – aggravate
3. Test patency, suctioning sterile H2O
Drainage
4. Lubricate (H2O soluble)
✓ Dark red
5. Insert – X suction if with resistance
X Bright red - bleeding
(carina), withdraw 1-2 cm then suction
Valsalva- for removal
intermittently and rotate, for 10- 15 sec
➢ 100 cc/hr - report
only, > 15 vasovagal reflexes will
H2O seal
stimulate PNS so dec HR, RR, BP
✓ 2 cm H2O
6. Hyper O2- 100 %
✓ Intermittent bubbling
✓ Tidaling- fluctuating (gradual)
Lung fluid management
X tidaling
Considerations:
Re-expansion
Oxygenation
Obstruction/leak
Hydration
No suction
Nutrition
Suction
CPT – Chest Physiotherapy – empty stomach -1°
✓ Continuous gentle bubbling
before or after meal
✓ Air vent always open
Percussion
✓ The deeper it will submerge the stronger is the
Vibration
suction
Postural drainage – gravity
✓ 20 cm H2O
Auscultate: UPper secretions- Heads UP
LOwer – head Low
Pneumonia
X beta- blocker – -olol cause inc. vasoconstriction
Causes: bacteria, fungi, virus
Good fluid indicator
Inflammation of lung parenchyma
Weight
5 Cardinal Symptoms
Urine Output
1. Chills
2. High-grade
Cor Pulmonale – “more water”
fever (101-
COPD + R-sided
105°F)
Dependent edema
3. Cough
Ascites
4. Sputum
JVD
5. Pleuritic chest pain- inc. pain during
Severe COPD – hypoxemia and hypoxia lead to inc.
inhalation
resistance and inc. pulmonary HTN leads to inc. Right
Types:
Ventricular Workload leads to Right Ventricular
1. CAP (Community Acquired P.)- <48°,
hypertrophy leads to Right sided HF
common rusty sputum, S. aureus or
Strep. P.
Asthma If continuous leads to fibrosis (scar) which
Hyper responsiveness of airway is irreversible
X to games STOP & GO (basketball, soccer) Dec. O2 – hypoxic drive, drive to breath
Inc. mucus mem/ production -edema signal (M. oblongata)
Bronchoconstriction Emphysema
Sunset – most pollen / airborne Elastic recoil
Initially- Respi Alkalosis, if untreated pt. dev. Air Barrel chest
trapping so CO2 cannot go out leads to Respi. Pleurisy – visceral (- nerve endings)
Acidosis (late) then respi failure Parietal (+ nerve ending)
Pulmonary function test- Dx Knife like PAIN!
Risk factor: pain radiates in abd and shoulder if phrenic
Intrinsic (within the pt) – extreme emotion, nerve is irritated
physical stress Mgt.: antibiotics, anti-inflammatory
Extrinsic – allergens, MSG
ZONE SYMPTOMS MGT

Green (Doing No cough Long term meds
well) No wheeze
No chest tightness
No SOB
✓ Usual activities Pulmonary Embolism
Peak flow meter: Causes:
80-100%
Yellow (Getting With cough Fast-acting 1. Thrombus
worse) wheeze bronchodilator – 2. Air
chest tightness albuterol (beta
SOB agonist)
3. Fat- long bone fracture (mech. Vent.)
Some usual activities 4. Amniotic Fluid
Peak flow meter: 5. Septic
50-79%
Red (Medical Inc SOB Albuterol Initial S/Sx
alert) Quick relief meds not Corticosteroids 1. Lung Sx
helpful Solu-cortef
X usual activities
a. DOB
Same condition or b. Inc RR
worse 24 hours after c. Chest
yellow zone
Peak Flow Meter: < pain
49% 2. Cardio
COPD – progressive airflow limitation Right Ventricle = JVD= Systemic
Risk factor: Smoking Dec surfactant leads to atelectasis
Air trapping Dec CO leads to shock (late sign)
Irreversible
S/Sx: Air Embolism – Air rises
Cough, clubbing of fingers (Chronic cyanotic) Mgt. = Positioning
O2 sat 90 % To trap it in Right Ventricle so LSL/L
Productive sputum Trendelenburg.
Dyspnea on exertion Mgt.:
Mgt: O2 low concentration 2-3 L/m o O2
Use venturi mask – dec con inc. flow o Inotropes (dopamine, dobutamine)
Purse lip breathing o Thrombolytics- “-kinase”
Close- ended question on assessment o Anticoagulants
Diet- Inc. CHON and dec Carb Oral (Warfarin) = IV (Heparin)
Chronic Bronchitis Delayed effect– monitor PTT
Inflammation 5-7 days
So OK if with Heparin 4. MDI should not be put inside the mouth (without
Monitor PT spacer) but
Antidote: Vit K(warfarin) held about two
Protamine SO4 (heparin) finger widths
DO Don’t (1 ½ inches)
Observe bleeding Combine Aspirin + Coumadin in front of the
Soft toothbrush, electric razor Contraceptives
Elastic stockings Prolonged sitting/standing mouth
Restrictive clothing
Trauma
Carbon Monoxide Poisoning
Useless & inc combustion
>50% - coma/death
Initial sign -cherry pink/red
5. Start to breath slowly, Press the top of the inhaler
Mgt.: Hyperbaric O2 therapy
once and keep breathing in slowly until you have
X O2 sat- false inc O2 reading
taken a full breath
Tuberculosis
6. Remove the inhaler from your mouth, and hold
Report to CDC
your breath for about 10 seconds, then breath out
Dec socio economic status
7. Interval between doses: 1 min
Immunocompromise
Wait peak bronchodilator 20 mins before adm of
Health care worker
corticosteroid (anti-inflammatory)
Test exposure – Mantoux skin test
If with spacer –put inside mouth– elderly/children
ID x 48- 72 hrs post reading
1. Competent - > 10 mm induration, palpable, no
redness
2. Immunocompromised ->5 mm
CXR – affirmation
Consolidation – upper part Glucocorticoids-
CPT – complete contraindication S/E – oral fungal infection – prevent rinse mouth
Sputum – AFB – confirmatory Inhaled
Use Hepa filter mask, N95 mask Beclomethasone diproprionate (Qvar)
Room- double door- NOT to open both at once Budesonide (Pulmicort turbohaler)
Respiratory Medications: Flunisolide (AeroBid)
Bronchodilators – S/E – SNS Fluticasone propionate (Flovert)
a. Sympathomimetics Triamcinolone (Azmacort)
Beta-adrenergic Agonist “erol” Oral
Albuterol (Proventil) Prednisone
Bitolterol Prednisolone
Salmeterol (Serevent) Inhaled Nonsteroidal Antiallergy Agents
Terbutaline (Brethine) mast cell stabilizer, DOC – asthma
Anticholinergics Cromolyn sodium, inhaled (Intal)
Ipratropium inhaled (atrovent) Nedocromil, inhaled (Tilade)
Tiotropium, inhaled (Spiriva) Leukotriene Modifiers
b. Methylxanthines LeukoTriene Receptor Antagonists
Theophylline, oral (theolair-SR, Theo-24, Long term maintenance
Uniphyl) Montelukast, Oral (Singulair)
Metered dose inhaler: Zafirlukast oral (Accolate)
1. Shake the inhaler well before use (3-4 shakes) Leukotriene Inhibitor
2. Remove the cap Zyflo
3. Breath out, away from your inhaler
Monoclonal Antibodies MUSCULOSKELETAL SYSTEM
Omalizumab (Xolair)
**for allergy-related asthma, administered SQ
Radiography – x-ray =
every 2-4 weeks
visualize hard tissue
Antihistamines
(bones and
Diphenhydramine (benadryl)
teeth)
Fexofenadine (Allegra)
Ask if pregnant,
Loratadine (Claritine)
remove metals
Cetirizine (Zyrtec)
Expectorants & Mucolytics
Expectorants – Guaifenesin (Humibid, Robitussin)
Bone Scan – radioactive with dye
Mucolytic Acetylcysteine (Mucomyst)
Radioisotope/ radio tracer inserted thru IV to
Antitussives
determine abnormal bone metabolism
Opioids
(osteoporosis, bone CA, osteitis deformans
Codeine
or Paget dse)
Codeine Phosphate
Pre- GAN
Codeine Sulfate
Get consent
Hydrocodone
Ask for allergy
Homatropine (Hycodan)
and pregnancy
Nonopioids
NPO 4-6 hrs
Diphenhydramine HCL Benadryl
Empty bladder for better visualization
Opioids Antagonists
Remove metals and jewelry
Nalmefene (Revex)
Post-
Naloxone HCl (Narcan)
Inc. OFI
Nalrexone (ReVia)
Without toilet precaution
Tuberculosis Drugs
Arthrography – visualize soft tissue (with dye) then
Rifampicin- S/E red orange body fluids
x-ray done
Isoniazid – peripheral neuritis – adm. Vit B6 -
Pre – GAN
pyridoxine – no to Parkinson drugs
3A’s
Pyrazinamide - hepatotoxic
Assess the joints
Ethambutol – optic neuritis
Avoid strenuous activity for at least 2 hrs
Streptomycin
Apply ice
CN8 – ototoxic. WOF deafness
Computed Tomography – computed generated radiation
Empty stomach for absorption
Pre – X pregnant
6 months
Get consent
2-3 weeks – non -infections
Assess if pt can lie for 30 mins
a. Evaluate effectiveness of anti-TB drugs by sputum
If with dye- assess for allergy
culture for AFB
Post Inc OFI (with dye)
b. Anti- TB drugs must be taken in combination to
avoid bacterial resistance
c. Empty stomach for maximum absorption
d. Avoid alcohol. Anti-TB drugs are hepatoxic
Magnetic Resonance Imaging – Use of strong magnetic

field
Pre-
No radiation so Ok for pregnant
Get consent
Assess if pt is claustrophobic (sedate if Myelography – injection of the dye to the (CSF)
ever) subarachnoid space to determine
X metals & jewelries spine pathology
Post- Pre
If sedated – safety prec Get consent
CI: pacemakers, metal Ask for allergy
implants, braces to avoid Inc OFI 24-48 hrs prior to procedure & on
burns the day NPO 4-6 hrs
Dual Energy X-Ray Post
Absorptiometry/DEXA- determine bone density & bone Assess movement and sensation
mass For 8 hrs
Pre- Ask consent Water dye- semi fowlers
Remove metals Oil- supine/flat
Discontinue Ca+ Supplement – 24-48 hours Air – Trendelenburg
before the procedure GOALS Treatment: for pt with injury, discomfort,
Osteoporosis meds- on the day before the immobility, deformity & disability provide comfort,
pro safety, mobility and independence
Post- none
Arthroscopy- the use of fiber optic scope to visualize Exercise:
joint structures Inc muscle strength (isometric (-) joint movement)
Done in OR, with GA anesthesia /LOC & Inc. ROM (isotonic (+) joint movement)
Pre- Assess ROM (joint) < 50 %
contraindicated Exercise Description
NPO 6-10 hours Passive ROM RN
Active assistive ROM RN + PT
Post- Active ROM PT
3A’s Active resistive ROM PT with/without RN
Elevate and extend Isometric PT
REFER: dec. ROM, pain, edema (if more
than 2 days), S/Sx of infection Good posture (the back should be straight) & Proper
Arthrocentesis – aspiration of synovial fluid body mechanics (even distribution of the weight)
Pre-Bedside, local Push- OK Pull- X
anesthesia, topical Safety and independence
Check consent Hand rails/ bathroom bars
3A’s Elevated toilet seat for pt with prosthesis
Electromyogram- use electrically charged needles to Slip proof rugs
determine muscle activity Snaps of closure and garterized for pt with
Pre Parkinson’s
Get consent Slip on shoes
Inform the patient that the procedure is Lever type door knobs
uncomfortable Wide diameter handles for pt with arthritis
Give topical anesthesia Foot pedal faucet
Post-
Bruising (apply warm - dec. discomfort & Osteoarthritis – degenerative joint dse; wear & tear
cold - dec bruising) – expected; assess
muscles
Affect weight bearing joints

Hypertrophy and spurring of the bone and Ankylosis (bones replaces scar tissue) – abnormal
erosion of cartilage stiffening
Risk factors S/Sx
Old age Joint pain
Obesity Dec. ROM
Poor posture Stiffening – not relieve by rest
Poor body mechanics Deformity
Degeneration of articular cartilage (shock 1. Swan neck deformity
absorber) leads to bone to bone contact 2. Ulnar deviation
leads to bone hypertrophy leads to bone 3. Boutonniere’s
spicules form deformity
S/Sx – joint pain leads to dec. ROM 4. Rheumatoid nodes –
Early sign – morning stiffness normally elbows and wrist &
relieve by rest, pain worse with activity joints
Distal Drug Therapy:
NSAIDS
a. Anti-arthritic- tumor necrosis factor blockers
substance, normal reaction for injury;
Etanercept (Enbrel) SQ
Proximal Infliximab (Remicade) IV
Drug therapy Adalimumab (Humiral) SQ
NSAIDS –WOF ototoxicity & S/E: respi. Infection, dizziness, headache
nephrotoxicity, hepatotoxic Mgt: x-ray every 6 months
N – Naproxen (Flanax), Assess breath sounds
Nabumetone (Relafen) Check for PTB prior to drug adm
S- Sulindac (Clinoril) b. Gold compounds: dec. immune system
A- Arcoxia, Arthrotec– combination of Chrysotherapy- slow acting, 3-6 months
Cytotec and diclofenac so ask if Give meds 1/wk every 6 months
pregnant Na thiomalate (myochrysine) IM
I - Ibuprofen (Motrin) Indomethacin Aurothioglucose (Solganal) IM
D- Diclofenac (Voltaren) S/E: MAPS
S - Salicylate Mouth sores
Aplastic anemia (dec
Herbal supplements: RBC, WBC, platelets)
Glucosamine – assess for allergy Proteinuria
(ingredient is exoskeleton of shellfish) Skin rash
Chondroitin – derive from sharks and pigs Auranofin (Ridaural) PO – 1/wk every
(religion) 6 month
Surgery: S/E: MAPS + Diarrhea
Osteotomy – bone reforming/reshaping c. Glucocorticoids – dec. immune sys
Total joint replacement (arthroplasty) Prednisone (Deltasone)
Dexamethasone (Decadron)
Rheumatoid Arthritis – Chronic type, inflammatory, Inc. Salt, Sugar, Sex
hereditary, progressive autoimmune The longer you take it inc risk for
Synovitis – inflammation of synovial tissue leads osteoporosis cause dec. Ca absorption
to Pannus formation (granulation of tissue) leads to Inc. appetite
Fibrous formation (Scar tissue) leads to Bony Inc. fluid retention
GI upset
K+ general
Thrombocytopenia Yeast
Mgt. Sprouts
Usually given with meals OK with:
Given in AM Water, fruits except with seeds, rice, milk,
Avoid large crowds cheese
Wear medic – alert bracelets Drug Therapy
Taper down the dose NSAIDS
Avoid these drugs: Steroids
Diuretic Anti-gout- GI upset so give with meals and
OHA Inc OFI
K+ Allopurinol (Xyloprim) – med of choice
Insulin Inhibit xanthine oxidase- enzyme use
Surgery: to convert purine to uric
Synovectomy – removal of synovial tissue Insoluble so inc OFI to dissolve the
Arthrodesis- use of metal rods limited to small joints drug
like fingers. Normally given up to 6 months then remove Do not give with aspirin cause it dec.
Arthroplasty- total replacement of joints effectivity of the drug
Juvenile RA – 2-5 & 9-12 yrs Colchicine (Colsalide) – prevent
Labs: deposition of uric acid, DOC- attack
Inflammatory- Inc WBC, Inc. ESR & Dec. pain and dec. inflammation
C-reactive protein – use to detect Inc. OFI to prevent deposition
progression of the dse of the pts Prebenecid (Benemid) – promotes
response to treatment excretion of uric acid, Inc OFI
Autoimmune Osteoporosis – metabolic disorder characterizes by dec.
(+) ANA – Antinuclear antibody bone density
(+) Rheumatoid factor Risk factor:
O –old age
Gout S-smoking &
AKA Podagra steroids use
Metabolic dse T-trauma
Inc. Purine Diet (liver convert purine to uric acid) E-endocrine disorder- hyperparathyroidism (bone
in hyperuricemia (no S/Sx) leads to Acute Gout to blood), Cushing’s, hypothyrocalcitonin (blood to
(with S/Sx) leads to intermittent asymptomatic bone)
leads to chronic gout- involvement of aorta, heart O-oophorectomy, menopause (dec. estrogen)
and kidney P-Pregnancy
Risk Factors: O-over intake of caffeine
o Purine diet R-race (Caucasians, Asians), Renal disorders-
o Alcohol because kidney synthesize Vit D
o Obesity O-obvious family history
S/Sx: joint pain, tophi formation- UA- crystalize S-small time frame
& deposits of joints, dec ROM I-Inadequate Ca & Vit D intake
Diet: dec. purine S-sedentary lifestyle- so weight bearing exercise,
Avoid: Anchovies, Sardines, Salmon walking
Legumes S/Sx:
Lentil Bone pain
Beer Reduced height
Organ meats (sweet breads), meats in Easily fractured
Always fall Surgery:
Kyphosis Percutaneous vertebroplasty- Corrects the hairline
Diet: fracture of spine
Swiss cheese Use of cement- subs methyl methacrylate
Swiss chard
Whole milk Paget’s Dse – AKA Osteitis Deformans
Non-fat, skim milk Cause: Unknown
Soy milk Inc osteoclast act and osteoblast (forming)
Tofu then bones become
Turnip green weak (mosaic like
Collards appearance)
Kale S/Sx:
NO cottage cheese- dec CA o Bone pain
Drug therapy: o Bowing of legs
Ca Vit D o Deformity
Pregnant 1500 mg o Inc head circumference
Non-preg. 1000 mg (Skull
Menopause with 1000 mg o thickening) “my hat no longer fits”
estrogen 400-600 IU/day
o Impaired hearing
replacement
Menopause 1500 mg – stapes
without estrogen o *REFER:
replacement invagination
(pouch) of the
Estrogen replacement therapy base of skull
Bone resorption inhibitors: o ( platybasia- is a
Calcitonin (Calcimar, Miacalcin) – blood to bone spinal disease of a
S/Sx: malformed
N/V relationship
Constipation between the
Hypokalemia (WOF) occipital bone and cervical spine) Ataxia and
Alendronate (Fosamax) – bisphosphonate retardation
Bone to blood Drug therapy:
Dec. osteoclasts (resorption) activity NSAIDs
Take upon arising with full glass of water Alendronate (Fosamax)
followed by NPO for 30 mins & remain Calcitonin
upright Ca & Vit D supplements
S/E:
o Esophageal irritation Osteomyelitis – S. aureus
o Flushing & rash Infection of
Raloxifene (Evista) – selective estrogen modulator bone with
receptor involvement of
Mimics some of the effects of the estrogen bone marrow
at the same time opposite the effects of S/Sx.
estrogen –inc mood swings, hot flushes, dec. o Fever
libido. o Bone pain
Fluid retention, weight gain, bloating of o Chills
breast, inc. clot tendencies, Inc. risk for o Discharges
DVT o Foul odor
Antibiotic therapy: Risk Factors:
Surgical Mgt.: Repetitive movements (typist)
Incision and drainage Arthritis – inflammation
Sequestrectomy- removal of infected bone Pregnancy – edema
Bone graft Difficulty forming or making a fist or
Amputation* grasping
S/Sx: pain, paresthesia, tenderness of your
Intervertebral Disc Herniation –slip disc thumb, index and middle finger
Risk Factors: Dx:
o Poor posture o Tinel’s Test – tap median carpal
o Poor body mechanics nerve
o Obesity o Phalen’s Test
o Trauma
Cervical – Upper extremity
C5-C6, C6-C7
S/Sx: pain, paresthesia, weakness, altered
reflexes
Lumbar – Lower Extremity
L4- L5, L5-L1
S/Sx: pain radiating from upper extremity
then back to hips and to lower extremity hit o Reverse Phalen’s
the sciatic nerve Drug therapy:
Steroid injection
NSAIDS
Vitamin B
Surgery:
Surgical release
Endoscopy release
Sleeping positions: Muculo - skeletal injuries
Cervical – anything but NO prone Sprain – ligaments
Lumbar – side-lying with hips and knees Strains – tendons
flexed/sims S/Sx: Pain, Tenderness, Swelling, Bruising
Drug therapy: Mgt: Rest
Muscle relaxant: S/E: both for dizziness and drowsiness Ice- within 24 hours then warm after
Methocarbamol (Robaxin) – change in the color Compress
of urine (green, brown, black) – expected Elevate
Cyclobenzaprine (Flexiril) – tachycardia so max Fracture – break in the continuity of the bone
2 weeks
Surgery: all surgical position – Flat on bed
Chemolysis – dissolves the disc using enzyme
chemopapain (derive from papaya)
Diskectomy – removal of disc
Diskectomy with fusion – spinal fusion S/Sx:
Laminectomy – removal of lamina 1. Bone pain
Laminotomy – dissection/division of lamina 2. Crepitus– hair
grating/cracking
Carpal Tunnel Syndrome – compression of median sound
nerve
3. Deformity – if in the hip- hip shortened “use cool setting of hair dryer”
externally rotated
4. Dec. distal pulses Compartment Syndrome – build-up of pressure inside a
5. Coolness of the affected extremity compartment that can expand
Internal pressure- cause bleeding and
Compound fracture: bone exposed to air cause edema
of break in the skin External pressure- cast is too tight
Complete fracture: bone is separated completely 5 Ps
into two parts o Pain - prio– unrelieved by narcotics,
Simple fracture: skin remains intact worsens during elevation
o Pallor
Initial care: o Paralysis
1. Immobilization o Pulseless
2. Use of splints o Paresthesia
3. Use sterile dressing Mgt:
Medical Mgt: Internal pressure
Reduction – manual manipulation of the bones Fasciotomy
Classification: Open- surgical External pressure
Close- non-surgical Windowing
Fixation – bone attachment Bivalving
Classification
Internal – use of wires, plates and screws
External – application of bandages,
splints and adhesions
Casts
Do’s
1. Let it dry
Plaster of Paris – 24-48 hrs
Fiberglass- 20-30 min
2. May hastens dying using the cool setting of
hair dryer, electric fan OK
3. Use palms
4. Rubber, plastic surfaces
Don’ts
1. Use of warm water- contribute hotspot prone
for infection
2. Don’t cover until dry – moistens- weak cast
3. Finger- prone to indentation leads to uneven
cast, prone to compartment syn. Cast Syndrome
4. Avoid cloth surfaces Pressure build up in the duodenum
Care for client: Cast that covers thoracic area
C- clean using mild soap & water, OK wiping Body cast/spica cast
A- Assess for temp. sensation of extremity, apply S/Sx:
ice, assess capillary refill Abdominal distension
S- sling provided, skin care Abdominal pain
T- turn pt every 2hrs Absent bowel sounds or stools (paralytic
E- Elevate & exercise ileus)
D- Do not put anything inside the cast Mgt: remove and replace cast
Surgery: Duodenojejunostomy- remove
duodenal necrotic part & connect with
jejunum
Complications of fracture:
Compartment & cast syndrome
Shock
Infection- osteomyelitis-amputation
Fat embolism – inc risk within 3 days, 7- 10 days Bryant’s traction – used in children <2 y.o to reduce
affect heart, lungs, brain == comp. DOB, tachycardia, femur fracture/stabilize hips
dyspnea, petechial rash, chest area or neck, face, arm, Russell’s traction – reduce fracture of hip/femur
upper ext. // only Mgt mech. vent 90° traction – used on femur if skin traction isn’t suitable
Avascular necrosis- amputation Buck’s traction – temporary immobilize fracture of the
Non-union, mal-union, delayed (6 months) leg
T – to exert a pulling force
R – relieve nerve compression
A- Allow alignment
C- control contractures
T- to decrease muscle spasm
I- injured part, maintained in position
O- observe if it hangs freely
N- no snugs on ropes Cervical traction –
stabilize spinal fracture/muscle spasm
Skeletal traction – anchored hard tissue
Weight: 25-45 lbs Crutches
Use of wires, pins, screws 2-3 finger breath to prevent damage to brachial plexus
Indication Elbow angle 15-30°
1. For long term use Standing crutches measurement from axilla to the sole
2. Adults of the foot same if patient lay just add 2” cause of the
3. Non-intact skin shoes
6-10 inches
Crutch gaits
2point gait-resembles normal -advance one crutch and
walking, transitional gait, fastest opposite leg together
gait, weight bearing - advance other crutch and leg
Mild bilateral weakness together
3point gait- indicated for - advance both crutches and bad
Crutchfield skeletal traction, 90-90 traction, Balance fracture, cast, sprains leg forward
-this is ONLY the non-weight -advance leg while keeping
skeletal traction, Halo (like gloria aroyo) bearing body weight on crutches
Skin traction – soft tissue 1 leg is odd -advance & hop
4point gait – weight bearing, -advance one crutch
Weight 4.5- 8 lbs indicated for patient with -advance opposite leg
Use of bandages, splints and adhesions osteo/rheumatoid, slowest gait -advance other crutch
Severe bilateral weakness -advance opposite leg
Indication: Swing to/through – bilateral -advance both crutches
1. Short term use paralysis, -lift both feet/ swing forward
2. Children weight bearing-both feet touch
the ground
3. Intact skin Non-weight bearing- only one
foot
Going up and down the stairs
Up with the Good

Down with the Bad
Canes
Elbow – 15-30°
* Holding the cane is always the GOOD side
*distance from foot- 6”
*cane should be at the level of the trochanter
Walkers
Always lift and roll
distance from foot- 8-10”
weight on hand bars
Pick them up, sat them down, walk through
Swing to them – slow
have pt tie the belongings in the side not the
front
Wheelchairs
Adult
Pedia
Paraplegia- Up/down
1. lower the bed at the level of the wheelchair
2. have the pt sit upright
Swing through
3. can also provide an overhead trapeze/sliding
4. wheelchair should be at bedside
Standing to sitting
Hemiplegia- Right/Left
Free one hand
1. lower the bed at the level of the wheelchair
Support arm rest
2. wheelchair should be positioned in an angle
Gently flex the good foot until scaled
3. provide gait belt, rotating disc
4. wheelchair is position at the good side, head
part
Joint Replacement:
Total hip replacement surgery
Avoid:
Flexion
Adduction
Internal Rotation
External Rotation
OK - Extend No dressing is indicated for pt with infection, trauma –
Abduction open for observation 7-10 days if no infection close- OR
Neutral Position
Use trochanter roll to prevent external rotation Prosthesis placement – early placement (closed), Open-
Post Hip Replacement delayed
Abduction wedge/pillow
Positioning- no bending Mgt.
Strong/firm chair Phantom limb pain- cause by the stimulation
Avoid turning in the opposite side or avoid along the neve pathway, give analgesis
weight bearing on affected leg Post-
Elevated commode Elevate the foot of the bed
Weight should be at the hand to avoid Post 24-48 hours position the patient prone,
prosthesis dislocation 3-4 hours/day for 30 mins to prevent
Total Knee Replacement contractures (mostly related to flexion)
Do not dangle With or without pillow is ok,
Avoid weight bearing on affected leg Avoid prolong sitting
Tourniquet at bedside
Amputation Massage skin
Risk factors / Complications of DM, Stump care- daily inspection using the
Avascular necrosis, Peripheral Vascular mirror, avoid using creams, lotions,
Dse, Trauma, Congenital Defects powders,
Closed skin flap- stiches/suture Can clean with mild soap & water
Residual sock- made of delicate fabric it
should be handwash and dried flat, replace
everyday
Residual socket should be moisture free
Lyme Dse:
Affects children
Common among woodland area- CT
Rigid dressing – rigid dressing helps contour Summer- June -Aug
stump Causative Agent: Borrelia Burgdorferi – tick bite
Instruct pt to use long sleeves & light-colored
clothing
1st stage: day of the bite to 1 month
S/Sx. Flu-like Sx, sore throat, fever, bull’s
eye, rash (small red lesions that expands laterally to form
concentric ring)
2nd stage: 1 month to 6 months – brain (bell’s
palsy) & heart involvement (dysrhythmias)
3rd stage: 6 months to 1 yr – S/Sx joint pain
c. Liver- production of Iron – needed for
hgb synthesis; Prob. Inc. risk for anemia –
iron supplement
d. Lymph nodes- maturation sites of
lymphocytes
e. Lungs
HEMATOLOGY
Medullary type – bone marrow to blood stem cell to:
Blood – connective tissue, organ exist in a fluid state
a. Myeloid stem cell – RBC, platelets, WBC
Function
(neutrophils, basophils, eosinophils, monocytes);
a. Transport O2 and eliminate CO2; hgb- O2
PRIO – IBA – Infection, Bleeding, Anemia
carrying of blood, red color
b. Lymphoid stem cell – Lymphocytes – B cells, T
2 types of normal hgb
cells, NK cells (natural killer); PRIO-Infection
1. HbF (fetal hgb) – birth up to 1.5 y.o
2 alpha and 2 gammas
Reticulocyte Endothelial System
2. HbA (Adult hgb) 1.5 till lifetime
Normal values:
2 alpha and 2 betas
RBC – 4,000,000 -5,200,000/cu mm
b. Transports hormones from the glands
Hgb- M- 13.8-18 g/dl
c. Maintains acid-base balance
F- 12-16 g/dl
d. Promotes body defense against antigen
Hct- M- 42-52%
invasion and disease
F-35-47%
e. Involved in the control of bleeding
WBC – 4,500-11,000/cu mm
Components
Platelet- 150,000-400,000/cu mm
Plasma- 55 % of the total blood; dissolves
ESR - inflammatory response
subs., electrolytes, vit. and minerals, clotting
M- 0-15 mm/hr
factors
F – 0-20 mm/hr
Buffy coat (leukocytes (wbc) and platelets);
Hemostasis – control of bleeding
< % of the total blood
1°type – platelets – adheres and aggregate to the site of
Erythrocytes – 45 % of the total blood
bleeding to temporarily seal the site
(RBC)
2°type- clotting factor – permanent control of bleeding
Thrombopoiesis - process of platelets formation

Pathology of the hematologic system – most
Leukopoiesis - process of WBC formation
hematologic diseases reflect in the hematopoietic,
Hematopoiesis – process of blood formation
hemostasis, and RES
Production, Maturation and proliferation
(erythropoiesis – RBC)
Pathology – Quantity and Quality balance
2 types
X dec. Anemia X immaure
1. Medullary – bone marrow (in major organ)
X inc. polycythemia OK – mature
a. Bone marrow aspiration –
OK- adequate amount
confirmation of blood dse
Dec. hgb – hypochromic - dec. color
2. Extra medullary- (RES) Reticulocyte
Microcytic
endothelial System- accessory organ
a. Spleen – graveyard of RBC- 120 days
lifespan; filters microorganism
b. Kidney – responsible for the production
of erythropoietin (for RBC synthesis); pt.
with kidney problem is at risk for anemia
and to prevent this give Epogen IV
(erythropoietin)
RBC- lifespan is 120 days c. Koilonychia – spooning of the nails
Size- 4-6 um, soft and palpable Nrsg Mgt:
Shape- biconcave, flexible a. Provide rest and comfort
Responsible hormone – EPO (erythropoietin) b. *Fe-supplementation – best absorb on
Important vit.: empty stomach, so before meals or in
Iron- hgb synthesis between meals, NO coffee, tea dec.
Vit B12 and folic acid – growth and development of rbc absorption; if with discomfort- give it
Shift left (immature-large) to right (mature-smaller) – with meals dec. absorption by 50%; give
with the use of Vit B12 and folic acid – lacking leads to vit C or with orange juice; take with
Megaloblastic anemia – larger than normal straw if liquid to prevent staining; Z-
track tech to prevent staining of skin
Normal EPO or erythropoiesis – c. Diet- #1 organ meat- liver, meats, green
Normal EPO production – post 120 days leads to leafy veg., raisins (dried dark fruits),
hypoxia triggers/signals the brain to signal the kidney to prunes, plum, blue berries
release or produce EPO then go to bone marrow and prod.
Mature RBC – with the use of Iron (liver- hgb synthesis), 2. Megaloblastic Anemia – macrocytic (big
Vit B12 (cyanocobalamin - intrinsic factor from the sizes), normochromic (N color), immature
parietal cells of the stomach, absorption of vit B12 in the -Cause:
small intestine – distal/terminal ileum) Folic acid deficiency
a. Poor diet
Abnormal – hypoxia-chronic pulmonary dse.(esp. b. Pregnancy
emphysema) –signals brain and kidney inc. RBC in the Vit B12 deficiency
bone marrow- polycythemia – most immature a. Poor diet
b. Malabsorption
Red blood cell disorders – 1. Pernicious anemia (lack of intrinsic
Anemia – dec. RBC leads to dec. O2 – compensate factor) – S/Sx: beefy red tongue and
inc HR and RR; activity intolerance and body malaise paresthesia
Principles of anemia: 2. Ileal dse – Crohns dse/diarrheal dse
a. Dec. RBC production Mgt: diet
b. Inc. RBC destruction Folic acid- green leafy veg
c. Chronic blood loss Vit. B12-meats or dairy
A. Hypoproliferative anemias products
1. Iron- deficiency Anemia (IDA) – dec. hgb, IF- Vit B12 IM injection-readily
hypochromic(pale), microcytic available-active
Cause: Nutritional deficiency 1st week- daily
Risk: exclusively BF infants so Fe-fortified 1st month-weekly
supplemental feeding @ 4-6 months 2nd month-inc. monthly for life
Manifestation: Oral vit B12- inactive form-
a. dyspnea on exertion; activity intolerance converted by the body if with
b. easy fatigability needing more periods intrinsic factor- active form B12
of rest Diagnosis
c. pallor (palmar) palpebral conjunction, Schilling test – assess vit B12 def.
nail beds Pre – pt given oral vit B12 upon
d. lethargy intake assess urine for absorption
Clinical correlation: a. Small amount of oral radioactive Vit
a. Pica B12, Parenteral non-radioactive Vit
b. Angular Cheilosis – cracking of the side B12
of the lips *24-48 hours urine test
Urine is radioactive (if absorb)- High altitude
poor diet Dehydration
Not radioactive (no absorption Infection
so cause is malabsorption) Emotional stress
b. Procedure (a) + intrinsic factor – Physical stress
same pre-pro with schilling test + IF; Acidosis
identify cause of malabsorption cold
Urine is radioactive (+) abs. HbS- 14 – 16 days
=pernicious anemia Hgb apathy
Urine still NOT radioactive (-) Abn hgb
abs. = ileal dse 75-80% replacement of globin chain
3. Aplastic Anemia – sudden cessation of Repel O2
hematopoiesis HbA N
is a rare dse caused by a dec. in or Alpha 2 and beta 2- 4 O2 carrier
damage/destruction to marrow stem cells, Abn- HbS
the microenvironment within the marrow, 1 alpha and 3 HbS- dec O2
and replacement of the marrow with fat. Cresent shape, sickling shape
Cause: Mgt: O2 and hydration therapy
a. Unknown Manifestations:
b. Autoimmune 1. Anemia
c. chemicals/drugs (pesticides, zidovudine 2. Jaundice – inc bilirubin due to early
(for HIV) chloramphenicol (antibiotic- hemolysis
A/E – in bone marrow- 3. Bone enlargement in children- due to
myelosuppression)) bone marrow workload manifestation
d. Chemo/radiation – inc. risk for IBA- bone pain
infection, bleeding, anemia 4. Infection
Dx test: CBC- dec RBC, WBC and 5. Multi-system failure
platelets= all down Pancytopenia Hepatomegaly (LUQ pain)
Mgt: blood transfusion, fresh whole Splenomegaly
blood Kidney failure
Bone marrow 6. CHEST syndrome- pain with breathing
exam/aspiration/biopsy- standard due to pulmonary infiltrates
confirmation Mgt:
Mgt: BT Hydration- 1st 2 is Prio in pt with sickle cell crisis-
1. Immunosuppressants -cyclosporine – O2 temp irreversible
A/E lymphadenopathy Pain mgt- vasoocclussive crisis- blockage of sickle
2. Steroids- S/E hyperglycemia, weight cell in the blood vessel; give morphine AVOID
gain, moon face appearance Demerol or meperidine (ass. seizure)- dec. O2 so
3. Chemotherapy – if cancer is the cause it will aggravate, warm compress (vasodil)
Exchange transfusion – PRBC
B. Hemolytic Anemia Other mgt:
1. Sickle cell anemia- is a recessive autosomal Bone marrow transplantation- IV at bedside
trait disorder that develops in the child when Hydroxyurea- meds to stimulate- prod of HgF-
both parent’s carriers of SC trait regardless of prevent sickling of cell
the gender\ Antibiotic
Risk factor-
a. Hereditary – African-american
b. Precipitating factors
Summary of Complications of Sickle cell Anemia b. Basophils-inc. rel. of histamine; b & c for
Organ Physical Findings Symptoms allergic response
involved c. Eosinophils- parasitic infection
Spleen Autosplenectomy, inc. Abdominal pain;
2. Agranulocytes – Without granules
infection (Esp. fever, signs of
pneumonia, infection a. Monocytes – mature in macrophages-
osteomyelitis) viral/fungal infections
Lungs Pulmonary infiltrate Chest pain,
dyspnea b. Lymphocytes- T cells – T4/CD4/T helper cells
CNS CVA Weakness (if (dec for pt with AIDS); Viral
severe); learning “L” is like
T8/CD8/T cytotoxic cells;
difficulties (if a “V”
mild) B cells – matures plasma cells, responsible for
Kidney Hematuria, inability to Dehydration production of antibodies to fight antigens
concentrate urine, renal
failure
Normal ratio: T4:T8
Heart Tachycardia, Weakness, fatigue, 2:1
cardiomegaly, CHF dyspnea AIDS 1:2 or < 200 CD4
Bone Widening of medullary Ache; bone pain.
spaces and cortical Esp hips
thinning; WBC Disorders
osteosclerosis;
avascular necrosis
I. Leukemia- Inc WBC immature
Liver Jaundice & gallstone Abdominal pain Cause: Unknown
formation; Classification:
hepatomegaly
Skin & Skin ulcers; poor Pain a. Stem cell line involved—
peripheral wound healing Myeloid (myelocytic) – IBA
Vasculature Lymphoid (lymphocytic)
Eye Scarring, hemorrhage, Dec. vision;
retinal detachment blindness b. Time in which symptoms evolve
Penis Priapism, impotence Pain, impotence Mx: < 1 yr- acute
Polycythemia Vera – increase volume of RBCs- >1yr – chronic
immature
Polycythemia 2° Polycytemia- Classification of leukemia
Vera-1°, true, pseudo/false/ Crite AML CML ALL CLL
myeloproliferative erythrocytosis ria
Cause Unknown Hypoxia to Chronic
Pulmonary Dse Age All Incidence Most Older adults,
Diagnosis CBC- inc. RBC, WBC & CBC- inc.RBC group incidence rises with common >60 yo
platelets; immature rises with age; childhood
Assessment Initial- facial flushing, Same with polycythemia age, peak median= 40- cancer; boy>
ruddy skin vera except pruritus 60yo 50 yo girl; peak 4
Hypervolemia-inc BP, yo to >15 yo
headache, dizziness CBC
Inc. Hct- Inc. risk thrombus
RBC Dec. Varies Dec. Varies
*pruritus (late sign)- inc.
basophils- inc. histamine WBC Low(Norm Inc Immature Inc.
Mgt. Therapeutic phlebotomy Treat the cause / hypoxia al) >100,000 lymphocytes Lymphocytes
(extraction of blood)- done Platele Varies Dec Varies
1x1 wk ts Dec
Inc. iron – inc No iron rich food & Clinica Insufficient Asymptomat Immature Lymphadenop
risk for supplement l Mx production ic lymphocytes athy
hardening Calamine lotion/ cocoa of normal SOB proliferate Splenomegaly
organs butter – to relieve pruritus
blood cells Splenomegal CNS Hepatomegaly
y involvement “B
White Blood Cell (leukocytes) Hepatomega Splenomegal symptoms”
ly y Anergy
Protection from infection Hepatomega
Protect the body from an antigen ly
1. Granulocytes – with granules in the cytoplasm
Surviv <1 yr 3-5 yrs 5 yrs 14 yrs (early
a. Neutrophils– major WBC in an acute al stage)
infection; 70-80% / None in rectum; bacterial 2.5 yrs (late
stage)
Comm Infection Infection Infection, Infection and leaks of the bones cause brittle bones then
on and and esp viral hemorrhage
cause hemorrhage hemorrhage (late)
fracture
of metastasis to the bones leads to hypercalcemia-
death renal stones/calculi so inc. OFI
Diagnosis
Acute lymphocytic Leukemia- 2/3 of children 1. Serum protein electrophoresis – M- CHON –
Nrsg. Dx: Risk for infection monoclonal protein
Diagnostics: bone marrow aspiration/ biopsy 2. Urine protein electrophoresis – bence-jones
Mgt.: Chemo CHON
WOF- Tumor Lysis Syndrome 3. CBC – (+) plasma cells – Normal confine in
Leakage in electrolyte leads to inc. K+, uric bone marrow
acid, Phosphorus and dec Ca 4. Bone marrow biopsy
Bone marrow transfusion Assessment:
Peripheral bone marrow transfusion Bone pain
Immature healthy cells, WBC to allow Brittle bones (pathologic Sx)
maturation B Sx
Bence-jones criteria – Urine and blood
II. Malignant Lymphomas – neoplasm of the cells Renal calculi
of lymphoid origin/painless enlarge lymph nodes Mgt.:
Mostly affecting cervical lymph nodes Inc. OFI
(neck) Chemo/radiation
Tumors usually start in lymph nodes but can Palliative Care (pain mgt.)
involve lymphoid tissue in the spleen, GIT Bleeding disorders
(wall of stomach), liver and bone marrow a. Idiopathic thrombocytopenic Purpura
B Sx- temp- high grade fever >38.5°C; Cause: Unknown, Autoimmune
Unintentional weight loss >10% of total S/Sx.-
body wt; night sweats
Early
dry purpura- superficial bleeding
Hodgkin’s Non-hodgkin’s petechiae, ecchymosis, bruises
Lymphoma – Lymphoma
fine needle biopsy Late:
Cause Epstein barr virus Immunosuppression Wet purpura- deep bleeding
-ex. Post-transplant Platelet count - <10-20,000
Age <20, >50 50-60
Gender Males> females Equal risk Hemoptysis, melena, epistaxis
Tumor cells Reed-sternberg cell Malignant B Heavy menses (spontaneous bleeding)
lymphocytes
WOF- intracranial bleeding- severe headache
Onset of Sx Mild anemia, Asymptomatic if with
painless lymph Sx late stage NI: neuro vital signs
enlargement Mgt.: Bleeding prec. BT-platelet concentrate,
(cervical)
Prognosis Good with B Sx- Poor with B Sx corticosteroids, immunosuppressants
generalized Ex. CLL; lymphoma- b. Hemophilia – deficiency of clotting factors
Sx- lymphoid in LN; multiple myeloma- X-linked autosomal recessive (male)
origin neoplasm of B cells or
plasma cells A (classic) -CF 8
Tx goal Chemo/radiation Chemo/radiation B (Christmas dse) – CF 9
S/Sx : hemarthrosis – bleeding joints early Mx
III. Multiple Myeloma – neoplasm of B cells/plasma Early: reluctant to move a body part
cells Late: Spontaneous bleeding; instability of the
Poor prognosis, palliative care (pain Mgt) joint; shock
Cause: metastasis to the bones (severe pain & it Mgt:
aggravates to PM or as days goes by) so Ca Cold compress
Bleeding prec. Assess v/s
BT-clotting factor concentrate (specific on Notify MD
what’s missing) fresh frozen plasma or Send/bring blood prod/tubing to lab/blood bank
cryoprecipitate
Neutropenia and bleeding precautions: Transfusion of whole blood & packed cells
Implementing neutropenia prec. Guidelines:
1. Thorough hand washing Pre:
2. Isolation-as much as possible private 1. Confirm, check, verify
3. No fresh flowers (stagnant water) 2. Explain
4. Change water in containers every shift 3. Baseline V/S
5. Low microbial diet- well cooked food; NO raw, 4. Standard precaution
fresh, milk; NO enemas, anything in rectum Intra:
6. Maintain skin integrity 1. Obtain blood, double-check
7. Provide total body and oral hygiene 2. Inspect
8. Maintain meticulous IV site care 3. Adm. within 30 min – to prevent hemolysis,
Implementing bleeding prec. microbial infection
1. Avoid anti-platelet medications 4. 1st 5 min- 5 ml/min
2. Avoid invasive procedures- IM injections, enemas 5. Monitor
(anything in rectum) 6. Adm. time 4 hours max ->4hours- discard
3. Avoid constipation- Inc OFI, fruits, veg, fiber Post:
4. No flossing of teeth, no commercial mouthwashes 1. Obtain v/s & compare with baseline
5. Soft-bristled toothbrush only 2. Dispose materials properly
6. Toothettes for mouth care if platelets <10,000, if 3. Document
gums bleed 4. Monitor the client
7. Discourage vigorous coughing/blowing of nose
8. Electric razor only IMMUNOLOGY
9. Pad side rails of bed 1. Natural/innate- ex. Skin
10. Trim nails short – Avoid nail clippers, cutter; OK a. Present at birth
with nail file b. Non-specific
11. Use paper tapes c. No memory
1st line of defense (natural)
Therapies in blood disorders ✓ Skin/mucous membrane
Blood transfusion ✓ Secretions
Complications: ✓ Acidity of the GIT & vagina
a. Febrile, non-hemolytic reaction- lab urine ✓ Cilia
collection 2nd line of defense (natural)
b. Acute hemolytic reaction – 1st 15 min; hematuria ✓ Phagocytosis
and low back pain ✓ Inflammation & fever
c. Allergic reaction ✓ Anti-microbial substance
d. Circulatory overload 3rd line of defense (Acquired)
e. Delayed hemolytic reaction- occurs 1-4 wks post ✓ Lymphocytes
transmission a. T cells – cell mediated response (gen.
f. Transmission of blood-borne dses – contamination effect. non-specific, wbc action)
WOF- Shock! - dec. BP b. B cells – humoral/antibody resp.-
Nrsg. Interventions: specific
Stop the transfusion (blood) ✓ Antibodies
KVO (NSS)
2. Acquired/Adaptive- ex. Chicken pox Assessment-
a. Not present @ birth a. Chest pain when taking a deep breath-
b. Specific pleuritic chest pain
c. Memory b. Fatigue
c. Fever
Vaccinations- provided to allow body to develop antibody d. Skin rash – butterfly rash/malar rash
Live/ attenuated/weakened = active e. Mouth sores
immunity = 2-3 months f. Photosensitivity
Ex. MMR, BCG, OPV, DPT g. Hair loss
Immunizations – readily available; given upon exposure h. Friction rub or
usually ending Ig – ex. EpIg -antirabies pleural friction
Ab- antibody – Favir Ab = leads to passive i. Lupus nephritis - common
immunity Mgt:
a. Corticosteroids
Additional notes: b. NSAIDS – except diclofenac/indomethacin-
a. Subjective- reassess,”Story from pt.” inc S/Sx of SLE
b. Objective- implement,”Observe” c. Hydrochloroquine- anti-inflammatory;
neutropenic prec; anti-malarial
Allergic Reaction: Criteria in Dx SLE
Allergy – inappropriate and often harmful response of 1. Malar (over the cheeks of the face)- butterfly
the immune system to normally harmless substances rash
Allergic Disorders 2. Discoid skin rash (patchy redness with
1. Anaphylaxis – sudden and severe allergic reaction hyperpigmentation that can cause scarring)
mediated by massive histamine release from cells; 3. Photosensitivity
Inc. Histamine- PNS- vasoconstriction = dec. 4. Mucous membrane ulcers
BP= bronchoconstriction = PRIO- airway 5. Arthritis
DOC- epinephrine SQ/IM 6. Pleuritis or pericarditis
B-sting- Epi ASAP / wof- airway 7. Kidney abnormalities (lupus nephritis)
2. Latex allergy- hypersensitivity to the proteins in 8. Brain irritation (manifested by seizures and
the natural rubber latex or the various chemicals psychosis “lupus cerebritis”)
used in the manufacturing process of the latex 9. Blood-count abnormalities
Risk factors: 10. Immunologic disorder
1. Myelomeningocele (spina bifida)- highest 11. Anti- nuclear antibody
2. Freq. exposure to latex: HC professionals,
hairdressers, food handler, auto mechanic II. Scleroderma – AKA firm skin fixed to tissue
3. Allergy to tropical fruits (banana, avocado, Autoimmune dse characterized by deposits
kiwi, pineapple, chestnuts, passion fruit, of collagen and fibrosis of the dermis,
strawberry) subcutaneous tissue, and sometimes deep
4. History of allergic skin disorders- atopic fascia; hardening/cold
dermatitis, eczema Cause/trigger: vasoconstriction; ass. with
Raynaud’s phenomenon – vasospasm
Diffuse Connective Tissue Diseases- autoimmune – Assessment-
connective tissue
I. Systemic Lupus Erythematous (SLE) – result of
disturbed immune regulation that causes an
exaggerated production of autoantibodies;
Common: Black, Hispanics, Asians, post puberty
20-30, female, hereditary, obese
Nrsg. Dx.- impaired skin integrity 1. Kaposi’s sarcoma- red- purplish spot/lesions in the
Mgt.: corticosteroids skin; Dx test- skin
biopsy
III. HIV/AIDS – universal precautions; neutropenic
prec. 2. B-cell lymphoma –
a retrovirus, carries genetic material in non- Hodgkin’s
ribonucleic acid (RNA), rather than DNA lymphoma
transmitted by way of body fluids that Others:
contain HIV or infected CD4 + T 1. Cryptococcus meningitis
lymphocytes 2. Herpes simplex
Stages Features Antiretroviral agent:
Initial/Acute Flu-like Sx, body Highly active antiretroviral Tx (HAART)
malaise, joint pain, Zidovudine – A/E- bone marrow suppression/
fever myelosuppression
HIV Asymptomatic No Sx; Start
Effectiveness: viral load test- the lower the better
monitoring the CD4/
T helper cells >500
Normal, check CARDIOVASCULAR SYSTEM
progression Atrium – damage – WOF- CVA, occlusion blood flow
HIV Symptomatic CD4 drop 200-499; a. Receives unO2 blood – Right
pt mx candida
b. Receives O2 blood – Left
infection
(candidiasis); white Ventricules- pump blood; Damage – CHF
or yellow patches a. Right to the lungs
(oral thrush) b. Left to the system
AIDS/ End stage CD4 <200; Aids Valves- prevents backflow and production of normal heart
defining sounds
characteristic WOF: endocarditis
HIV positive
Mx: heart murmurs- passage of blood- abnormal valves
Dx- Elisa (2x +) confirmatory
AV valves- lining endocardium
Western Blot (1 +)
Closing cause ventricular contraction
Manifestations:
S1- lub sound/ systole
Respiratory:
Damage of AV valves – prolapse or
1. Pneumocystis carinii pneumonia, pneumocystis
regurgitation, systolic murmurs
jiroveci
a. Tricuspid
2. Mycobacterium avium complex “Close-Open”
b. Mitral/bicuspid
3. Tb Lub-Dub
GI
Semilunar Valves – open, ventricular relaxation
1. Diarrhea- dec Na+ & K+
S2 sound, dub, diastole
2. Oral candidiasis – fungal
Damage to semilunar valves causes diastolic
Mgt.- Nystatin – swish and swallow; DO NOT
murmurs
eat or drink at least 30 mins
3. Wasting syndrome – Cachexia (muscle wasting)
a. Pulmonic valve
Give megestrol (megace) – progesterone
b. Aortic valve
Zinc supp. – improve taste
Vein- (back) towards the heart
Oncologic: = underlying cause= immunosuppression
Artery- away from the heart
ECG
The limb leads
Conduction System of the heart

SA node – atrial depolarization/contraction
1°pacemaker =60-100bpm
P wave then Ventricular
edepolarization/contraction (QRS) then
ventricular repolarization (T wave)-most
sensitive part/vulnerable
SA node then to AV node then to Bundle of His (right and
left) then to purkinje fibers from AV noede to purkinje
fibers – ventricular depolarization/contraction the
ventricular relaxation
Electrocardiogram (ECG)
The Chest limbs
V1- 4th ICS R sternal border

V2- 4th ICS L sternal border
ECG parameters V3- midway V2 & V4
1. P wave- small, round and upright V4-5th ICS- mid-clavicular line
2. QRS complex- narrow; 0.6-0.10sec approximately V5-Anterior axillary line
1-2 small boxes V6- Mid axillary line
3. PR interval- QRS 2x- 0.12-0.20 sec- 3-5 small
boxes
4. Rate- 60-100 bpm- if regular # of waves in a given
6 sec x 10 = 60 sec
5. Rhythm- regular/irregular
Ca channel blocker- “dipine”
1. P wave – Normal or partially hidden
2. QRS complex – Normal; .08 sec
3. PR interval – intermediate
4. Rate – >120 bpm
5. Rhythm – regular
NOTE: if you cannot identify the P waves automatic NOT

a sinus rhythm
Atrial rhythms – SA node fails! Impulse coming fr AV
node; Abnormal P waves Normal QRS
Sinus rhythms 1. Atrial flutter –saw tooth

SA node pacing DOC-stable- Na channel blockers- procainamide
1. Normal sinus and quinidine
Unstable – cardioversion – unstable
tachycardia with pulse
1. P wave – abnormal
2. QRS complex – Normal
3. PR interval
4. Rate
1. P wave - Normal 5. Rhythm – regular (QRS)
2. QRS complex - Normal
3. PR interval - Normal
4. Rate – 70 bpm- 100 bpm
2. Sinus bradycardia – Normal- athletes and elderly
DOC- atropine SO4 (stable) – Inc HR
PRIO for unstable/emergency- dec. BP
Transcutaneous pacing-temporary inc. HR
2. Atrial fibrillation-(chaotic) Same mgt/doc with
Pacing- no bradycardia
atrial flutter and additional Na channel blockers +
Pacemaker-permanent
thrombolytics + anticoagulants + antiplatelets
Inc. risk for thrombus = fibrillation = stasis
in the heart = thrombus/clot = dec O2 =
CVA
1. P wave – none/abnormal
2. QRS complex – Normal
1. P wave - Normal
3. PR interval
2. QRS complex - Normal
4. Rate
3. PR interval – 0.12-0.20
5. Rhythm – irregular/chaotic (QRS)
4. Rate – <60 bpm
3. Sinus tachycardia- DOC-beta-blockers”olol”
3. Supraventricular tachycardia (SVT) – (bizarre)
p buried t wave; p wave unidentified
DOC- stable – Adenosine- 1st line drug
Beta-blocker
Ca channel blocker
Unstable- cardioversion (with pulse)
3. Ventricular Fibrillation – no pulse / no

QRS/chaotic
Or Mgt- Defibrillation
Epinephrine
Amiodarone
Lidocaine
MgSO4
Before with vasopressin
Ventricular rhythms – SA node & AV node fail!

Ventricles will shoulder responsibility of pacing the heart
4. Asystole – Mgt: CPR + intubate

1. Premature Ventricular Contraction (PVC) –
Compression- push hard & fast- rate 100-200/min
DOC-Na channel blockers-
Depth: Adult- 2-2.5”
Lidocaine/Amiodarone
Child - 1.5-2”
O2 Supp
Infant- 1.5” -1/3 of anteroposterior chest
*Refer 3 or more consecutive PVC leads to V
diameter
tach./ non sustained V tach ; > 6 in a min or
Airway
intermittent PVCs in a min
Breathing
DOC: epinephrine
Do not defibrillate as long as asystole
Ok with pulseless V-tach or V-fib
Heart Blocks
2. Ventricular Tachycardia – wide QRS Causes: ischemia; Inc. beta blockers
Mgt: monomorphic V tach- single foci Mgt: atropine; pacemaker – no blockage, permanent
a. Pulseless- defibrillation
b. With pulse- cardioversion Heartblock algorithm
c. Lidocaine
Mgt: polymorphic V tach – multiple foci PR interval – prolonged (>.20 sec)
Ex. Torsade’s de pointes – dec Mg so give Constant (same) – P:QRS
MgSO4 a. P = QRS - 1° AV block; 1st/early-atropine SO4
b. P>QRS - 2° type II (Mobitz II) – dropped beat; no
QRS sometimes
Variable (irregular) – reset (another Normal PR Indication Unstable tachycardia Pulseless &
unresponsive
interval) Purpose To temporarily stop the To contract the heart
a. With reset - 2° type I (wenkebach/Mobitz I) – with heart to convert to stable
cycle rhythm; * synchronize to
R wave
b. Without reset – complete heart block -3° heart Voltage 50-100-150-200 joules 3x 1st -200
block 2nd – 300
3rd – 360
Automated external Automated internal
defibrillator (AED) defibrillator (AID)
Procedure 1.Turn ON With pacemaker
2. Attach the chest pads 1.If shock deliver
3. Push analyze button (REFER!)
4. Announce clear 2.Keep diary ADL’s-to
5. Wait for shock to be determine factors that
delivered trigger defib.
6. 3x shock- if needed 3. NO MRI, high
voltages electricity,
contact sports to prevent
dislodge
Artificial Pacemaker Holter Monitor

1.Count heart rate and PR daily Ambulatory ECG- 24-
2.Dizziness- REFER!-sign dec. 48°monitoring
cardiac output *interfere -electric devices
3. NO MRI, electric devices, no -wetting- swimming, complete
contact sports, at least 6 inches - shower, profuse sweating
Or contact Battery – AA- change every
4. Battery-10-20 years life span 24hours
Disorders in the heart

A. Coronary artery dse – common among Caucasians,
female, inc. cholesterol= dec HDL (good) & inc
Managing Dysrhythmias: Modalities LDL(bad) leads to plaque formation leads to
Antidysrhythmic Drugs atherosclerosis then dec. O2 to myocardium leading
Class I-Na-channel blockers Class II- beta-blockers “olol”
Atrial – procainamide, PNS effect to MI
Quinidine WOF: Bronchospasm
Ventricular- Lidocaine Bronchoconstriction Cardiac catheterization – coronary angiogram
CI. Asthma, COPD, wheezing
S/E: DAN – Mx-bronchoconstriction Done: cath lab with local anesthesia
Diarrhea Assess: femoral ARTERY
Abdominal cramps
N/V Prior: asked allergy to shellfish to avoid anaphylaxis;
Class III – K+ channel Class IV- Ca+ channel if allergic to shellfish its ok but you have to give anti-
blockers blockers “-dipine” histamine; if renal-use other contrast agent
Amiodarone – S/E prolonged Verapamil
use -bluish discoloration of the Diltiazem Post:
skin * AVOID- grapefruit juice, 1. Provide pt with sand bag over access site to
*AVOID – St. john’s wort – potentiates or aggravate
herbal meds, antidepressants – hypotension prevent bleeding & clot
dec effectiveness 2. Keep affected leg straight 4-6 hours
3. Keep CBR 1st 12°without bathroom privileges
Cardioversion Defibrillation 4. WOF: absent distal pulses (-)
Common sign for both “chest pain” Antiplatelets Thrombolytics/fibrinolytics
Angina Myocardial Infarction (MI) Aspirin “clot busters”
<20 min chest pain >30 min (not relieve by NTG) Clopidogrel “kinase”, “phase”
1. Stable – occur with activity 1. Ischemia – dec. O2, Inc. Dipyridamole Streptokinase
esp strenuous lactic acid, T wave inversion Ticlopidine Altephase
2.Unstable- even @ rest require 2. Injury-inflammation A/E: bleeding A/E: bleeding
confinement Troponin I- most sensitive S/E: GI irritants – with or Antidote: Aminocaproic acid
3.Prinzmetal- even @ rest CK-MB post meals (amicar)
require confinement; variant- Myoglobin *given to MI pt within 6°onset
same hour hr a day WBC only
DOC: vasodilator – 1st line - ESR
NTG C-reactive protein Anticoagulants- prevents clot formation Alert
Other: isosorbide - ST segment elevation common
S/E: dec BP = before and 3. Infarction – necrosis Blood thinners
in NCLEX
during drug administration - severe depletion of Q wave Heparin – aPTT/PTT- Route: IV
= dizziness (sit, lying, rest) AKA pathologic Q wave
Clotting time: Normal therapeutic value- 1.5-2.5 X
= headache - Mgt: Morphine SO4
NTG- sublingual, store in dark O2 normal / > normal
bottles (drug photosensitive), six Naloxone (Narcan- With heparin- increase Normal but still NO bleeding
months – effectiveness antidote)
- take 1tab post pain another Aspirin aPTT- Normal – 20-36 sec. (thera. Range (T.R.)- 60-
1tab every 5 min (3x) only *complete relief of pain so 80)
- AVOID: report even with slightest; even
1. sildenafil (Viagra) -potent 1 out of 10; Chest pain with MI
clotting time – Normal 5-10 min = 16-20 mins
vasodilator; lead to fatal – REFER! For MI antidote- protamine SO4
hypotension Warfarin- oral
2. alcohol- inc. S/E Dysrhythmias – leading cause of
Transdermal -patch death inc. alert medic, require safeguards, double check
- chest-non-hairy with other RN before adm.
- 12-16 hours indicated
- 24 hours changing
Normal PT- 9-12 sec (T.R = <30 sec)
- 8hour patch free period – to INR-2-3 sec (T.R. = 4.5 sec)
dec. tolerance, ideally at night Antidote: Vit K. Enoxaparin_SubQ_use as a
time
maintenance, No antidote but
Treatment for CAD if ask same with heparin
D.O.C. for Vasoocclusion
AntihyperLIPIDemics a. Percutaneous Transluminal Coronary
1. HMG-COA Reductase inhibitor- “statins” Angioplasty (PTCA) – “plasty”-repair
Teratogenic Stent to keep the blood vessel open
LDL dec with stent – post surgery – antiplatelet
Inc. HDL therapy
Pm/@ night time cath lab with local anesthesia
Inc. cholesterol synthesis for milder case
DO- inc. function test (hepatotoxic)
Annual eye exam- cataract
Report- muscle weakness-sign of
rhabdomyolisis – breakdown of muscle
tissues
2. Fibric Acid Derivatives – Gemfibrozil, Fenofibrate
Action: dec. triglycerides
3. Bile acid sequestrants – Cholestyramine (Questran), b. Coronary artery bypass graft (CABG)
bind with fats and excreted via stool Done – OR with general anesthesia
S/E: constipation- dec fat soluble vit ADEK Graft; saphenous vein (leg)
Post-pro.: attach to drain
CTT/mediastinal tube <100 ml/hr
Post 1st 2 hours – CBR & progress activity
depending on rehab
Coronary arteriography – common comp.- Cardiac tamponade- > pericardial fluid leads to
hemorrhage; S/Sx: shock pericardial effusion, distant muffled heart sound, >30 ml
fluid which compresses the heart, so cardiac output
decreases leads to shock – hypo, tachy, tachy, altered
LOC, pulsus paradoxus = dec. systolic BP during
inhalation; congestion- JVD, inc. CVP
Mgt.
Pericardiocentesis
O2
IV vasopressor – inc. vasoconstriction, dec. to
relieve S/Sx of shock ex. Norepinephrine drip
Pericardium – something to do with the pericardial fluid

Pericardial sac/space – 30 ml- to prevent friction during
contraction
Myocardium- Muscle layer, for contraction. pump
Endocardium – lines the valves
Congestive Heart Failure – failure of ventricles
Inflammatory heart diseases *most useful monitor – B-type natriuretic
Generally, cause by: URTI- strep and staph. – Mgt: peptide
Penicillin and vancomycin; autoimmune – Pt with SOB, fatigue possible HF
corticosteroids- anti-inflammatory Left-sided Heart Failure – Lungs (backflow)
Bibasilar crackles
Endocarditis – “valves”; vegetation- accumulation, clots, DOB- Paroxysmal nocturnal dyspnea – DOB at night
fibrin and thrombus leads to murmurs and infective Orthopnea – DOB lying supine
emboli, in the skin: purpura, petechiae and nodules Frothy sputum – non-productive cough-hemoptysis
(janeway’s node – nodules in the fingers or lesions which Dec. Cardiac Output leads to dec. LOC or dizziness
is painless) (brain) and oliguria (kidney)
Right-sided Heart Failure – System (backflow)
IVC-inferior vena cava
Hepatomegaly – RUQ pain
Ascites
Inc IVF
Pt with vegetation on mitral valve reports Dependent edema
sudden left foot pain, no pulse palpable in Left foot, cold, SVC- superior vena cava – Inc ICP and dec. LOC
pale. Action: REFER! Periorbital facial edema
Arterial occlusion needs balloon angioplasty surgery JVD
Pulmonary edema
Myocarditis “muscles” – dysrhythmias or ischemia – Mgt- MORFUN
chest pain with persistent fatigue. Morphine
O2
Pericarditis “pericardial fluid” – dec. amount of Rest: high fowlers
pericardial fluid leads to pericardial friction rub which Foley cath
inc. pain esp. supine & inhalation so dec. BP, JVD fUrosemide
Severe cases if left untreated WOF: Cardiac NTG
tamponade
Snow storm -x-ray for fat embolism
Medical Mgt:
Prob. Dec contractility and inc blood volume
1. Digoxin – 0.5-2 ng/ml
(+) inotropic – inc contractility
(-) chronotropic- dec HR
Hold if HR < 60 bpm – adult, <100 infant
• Assess HR & PR daily full minute
• WOF: hypokalemia- inc toxicity
Disorders of the Blood Vessels – in general WOF
VANDA
Orthostatic Hypotension
Visual disturbances
I. Hypertension
Anorexia (1st)
RAAS activation or Renin Angiotensin Aldosterone
N/V
System
Diarrhea
Abdominal cramps/pain
• Antidote: Digibind
2. Dobutamine/Dopamine - (+) inotropic/
chronotropic
3. Diuretics- if taken with digitalis expect to
use K+ sparing
Muga scan- AKA myocardial perfusion scan/imaging
* NO iodine DOC:
With radioisotope IV tracer ACE inhibitor “-pril”
CI: pregnant An hour before meal
AKA: Thallium Scan- with technecium Cough (dry, persistent & irritating)- REFER! So
they can use an alternative drug
Measurement of Heart Function Edema eyes and face / Elevate K+
CVP- N- 5-10 cm H2O WOF: Inc K+ - A/E - REFER!
3-8 mmHg No salt substitute – rich in K+
Measure: Right heart function ARB-Angiotensin II Receptor Blockers “sartan”
End of right heart WOF: Inc K+
Inc CVP- FVE A1 adrenegic blockers “zocin”
Dec CVP- FVD Ex. Prazocin (minipress)
Beta-blockers “olol”
Ca+ channel blocker “dipine”
Diuretics
II. Abdominal Aortic Aneurysm

Walking time bomb
PCWP – N-8-12 mmHg Clot, plaque, thrombus = pulsating abdominal
Measure: Left heart function mass (DO NOT palpate – inc. rupture-
Swan-ganz cath-balloon cath tip is in aneurysm - SHOCK) = worsened by HTN =
pulmonary artey thinning arterial wall = inc. risk impending
Inc PCWP- pulmonary congestion rupture
Dec PCWP- shock S/Sx: dec back pain/pelvic pain or flank pain
(warning/impending sign) sudden relief =
rupture so pt will expire = REPORT!
Mgt: “statins” “thrombolytics” “anticoagulants”
“antiplatelets” “anti-hypertensive meds”
Best- ASAP- Diuretics
Surgery: Endovascular Stenting Corticosteroids
Position: semi-high fowlers
III. Disorders of Peripheral Vascular System Avoid Bp & venipuncture of the upper extremities
Arterial Venous
Too low perfusion too much perfusion DVT- Deep Vein Thrombosis
Skin- cool skin-warm Cause: due to prolong immobilization = stasis = thrombus
Pale flush/redness = dec. venous return or congestion = swelling (calf
Pulseless Swollen, bounding pulses circumference reddened/flush/warm), bounding pulses, (+)
Arterial Disorders homan’s sign – calf tenderness
1. Peripheral Arterial Dse – CAD = intermittent Mgt: thrombolytics if diagnose avoid
claudication (pain with activity) ambulation to prevent dislodge (early
Mgt.: CBR 5-7 days ambulation), bed rest, anti-embolic/TED
DOC: Statins stocking, D-dimer test – detect clot
Thrombolytics formation
Anticoagulants
Antiplatelets Varicose Veins
NSAIDS Prolong standing = incompetent veins = pedal cramps
2. Buerger’s Dse “thromboangitis obliterans” = popliteal = vein dilation (spider veins)
Common among Boys, Bilateral, Baba (leg) Teaching: NO crossing of legs and NO tight jeans
Due: smoking / auto-immune = vasculitis Tx: Sclerotherapy -inject agent to dec. vein
(persistent redness of the lower extremities) Laser
= stasis = thrombus = dec O2 = gangrene = Vein stripping / Ligations
amputation
Combination with peripheral arterial dse
Mgt: thrombolytics, corticosteroids PSYCHIATRIC AND MENTAL
3. Raynaud’d Dse
HEALTH NURSING
Female, hands and fingers
White(pale)-blue(cyanosis)-red (rubor or
Tips in Answering Psychosocial Integrity Questions
flush-sudden gush of blood) phenomenon
SAFETY – psychiatric, danger or
Cause: cold climate/temp, stress leads to
emergency
vasospasm (initial constriction of vessels-
Avoid touching autistic pt
dec. blood supply) – White blue red P.
Present reality, Acknowledge, Allow
DOC: Ca+ channel blockers – reverse
verbalization of feelings (delusional pt)
vasospasm, gloves
Encourage verbalization of feelings – if pt
is out of danger, during admission
Venous Disorders
Promote/remind self-care and adaptation
SVC Syndrome:
skills- assist pt with ADL’s/ physiological
Oncologic emergency
needs (circulation- in catatonic state)
Severe complication cancer
Non- Therapeutic Communication
Ex. Lung carcinoma = obstruction/congestion SVC
Ignoring the pt, Flattery
Late – Inc ICP & dec LOC
Giving opinion/telling the pt what to do “In my
Early: periorbital/facial edema, JVD
opinion, you should”
Chest pain, DOB, non-productive cough
False reassurance “Don’t worry everything will be
Edema & flushing upper extremities
alright”
Generalized cyanosis below
Advising. “You should do this” – No to battered
Mgt.:
wife syndrome
Chemo
Changing the subject, Challenging
Defending “All the nurses here are great” Schizoid personality disorder “loners”,
Giving approval or disapproval naturally detached
Belittling “Everyone else feels the same. Don’t be Schizotypal personality disorder “eccentric”,
concerned too much,” – always validate the concern magical thinking, very superior
or feelings
Judging “If you had only listened to the doctor. It’s Psychosexual (Freud)
your mistake.” a. Oral- Infancy
WHY? – not good for asking feelings, never put pt b. Anal – toddlerhood
into a defensive state, depending on the situation- c. Phallic(oedipal) – Pre-school
OK for simple facts d. Latency (quiet stage)- School age
e. Genital – adolescent and young adulthood
Therapeutic Communication Psychosocial theory (Erickson)
Exploring, Using silence Age +Value -Value Factor
Restating or reflecting, Making observations group
0-18mons – Trust and Mistrust, Satisfaction of
Is a priority but only after a client is out of
infancy safety, oral paranoid needs thru
immediate physical danger fixation personality feedings
Always ask open-ended questions and seek for more disorder
(suspicion)
information (not yes-no) overgratification
Always stay in here and now! Keep focused -gullibility
(depressed pt, manic pt, crisis) on issues at hand, 18 mons-3 Autonomy Shame vs doubt- Toilet training
yrs Independenc dec self-esteem- Adequate- good
refocusing Toddlerhoo e depression impulse control
Always consider developmental, cultural, and d Dependence Too lax-
impulsive(manic
physical variables when responding )
Never assert personal opinion about anything or Too Strict-
OCPD
anyone
3-6 yrs Initiative Guilt Sexual curiosity,
Pre-school conscience
Conceptual Frameworks develop @ 5 so
best time to
Structures of personality teach the child
a. Super ego – the conscience, morality principle the appropriate
social behavior
OCD
Antisocial- if not
Depressed prevented
Anorexia 6-12 yrs Industry and Inferiority Learning
School Age competence complex
Antisocial 12-20yrs Identity Role confusion, Vocation, Body
b. Id- the pleasure principle, avoid pain Adolescenc Emotional emotional image
Manic pt- very restless e stability & immaturity, disturbance-
long-term short term Anorexia/
Antisocial – they violate rules thinking thinking Bulimia
Narcissistic – too loving Equate love with
sex
Addictions 20-35 yrs Intimacy, Isolation Relationship
Anhedonia- too little preference with ID – Early The pt able Withdrawn
inability to experience pleasure adulthood to give and
receive love,
c. Ego – the reality principle, balance Id and super interpersonal
ego 35-65 ys Generativity Stagnation- Support
Middle Give support depression
For schizophrenia and schizophreniforms adulthood to self and Self-centered
✓ Psychosis marked X reality others
✓ Ambivalence X balance 65 yr up Ego integrity Despair Satisfying past
Older adult Fulfillment Regrets
Schizophreniforms
Human behavior Ex. A reviewee blames the review center for
Meaningful, attempts to communicate the meaning his failure in the board exam
90 % - non-verbal e. Regression – returning to an earlier and more
10 %- verbal comfortable level of adjustment
Purposeful attempt to meet needs (biologic and Ex. A 4 years old begins to wet his pants
psychological) following the birth of his baby brother
Response to stimulus f. Reaction formation- developing conscious
Learned – permanent change attitude and behaviors that are the opposite of
We learn to inc reinforcement (Positive-reward, what one really feels or desires to do
Negative-temper tantrums) vs punishment (dec/stop Ex. A woman who is very angry with her
induce pain and fear) boss and would like to quit her job may
Lying – loud (speak) anxious (slow voice), look for instead overly kind and generous toward her
pattern of behavior, Anxious boss and express a desire to keep working
there forever
Defense Mechanism (DM) g. Supression – the conscious, deliberate forgetting
Unwanted or painful stimuli = inc anxiety/tension = of unacceptable or painful thoughts, ideas and
triggers use of defense mechanism = Normal = feelings
purpose-dec. anxiety until no more actions necessary Ex. A young woman says she is not ready to
or to maintain equilibrium; Adequate use= acceptance talk about abuse as a child
-problem resolution or maintain equilibrium; Overuse
– no acceptance, no resolution =psychopathology, II. Less Primitive, More Mature DM
results to inc anxiety, depression, trauma Step up from the primitive DM
Employed mostly by adults
I. Primitive DM a. Displacement- redirection of emotional feelings
Do little to try and resolve underlying issues or from original idea, person or object to a less
problems threatening one
Less effective over long term Ex. A superior berates a head nurse, and
Very effective for short term, hence are favored when she goes back to the unit, speaks
by many harshly to the staff
a. Conversion – expression of intrapsychic conflict b. Identification – the unconscious attempt to
symbolically through physical symptoms change oneself to resemble an admired person
Ex. A student develop diarrhea on the day of Ex. An adolescent dress like a rock star &
NCLEX-exam mimics his behavior
b. Denial – conscious refusal to accept reality or c. Rationalization – An attempt to make
fact acting as if painful event, thought or feeling unacceptable feelings and behavior acceptable by
did not exist, common for alcoholic justifying the behavior; making logical excuses
Ex. A person who is functioning alcoholic Ex. A student fails the examination and says
will simply deny they have a drinking the lectures were poorly organized
problem, pointing to how will they handle d. Repression – involuntary & unconscious
their job and relationship forgetting of unbearable ideas and impulses
c. Dissociation – Separation and detachment of Ex. An accident victim does not remember
emotional significance & affect from an idea or a the details of an accident
situation, common- PTSD e. Substitution – Replacement of an unacceptable
Ex. A client grins & chuckles when telling need, attitude or emotion with one that is more
about his automobile accident and its tragic acceptable
consequences Ex. A woman rushes into marriage
d. Projection- attributing intolerable wishes, following a breakup with her bf
feelings and motivations to other persons
f. Undoing- an attempt to actually or symbolically Encourage client to discuss feelings about termination
take away a previously consciously intolerable (final and clear)
action or experience Major Task: Assist the client to review what
Ex. A mother who has just punished her he/she has learned and transfer his learning to his
child gives him a cookie. relationship with other
Mental status examination
III. Mature DM a. General Description – general physical
Most constructive and helpful appearance of pt
May require practice and effort to put into daily b. Mood and Affect- emotional expression/state
use Blunted- severe reduction of emotional
a. Compensation- an attempt to make up for real or expression
fancied deficiencies Flat – no reaction
Ex. A high school student does poorly in Labile – mood swing/ extreme emotional
academics but becomes a talented artist change
b. Sublimation – Diversion of consciously Inappropriate – opposite emotional state
unacceptable instinctual drives into personally & c. Speech – rate and tone
socially accepted areas d. Perception – senses are involved “sees, perceives,
Ex. Strong sexual urges are diverted into hears, feels, taste, smells”
creative arts like painting and sculpture Hallucinations (auditory, visual, olfactory,
gustatory, tactile), without stimulus
Phases of therapeutic Nurse-Patient Relationship Illusions – with stimulus
Goal: *Nrsg Dx: Alteration in sensory
Pre-interaction Phase- Self-exploration perception
Major Task: Develop Self-awareness e. Thought- disturbance to how pt think
Initial NI: show of acceptance/neutral Thought process
Countertransference- nurse reminded of someone she Clang associations – rhyming of similar
knows sounding words; repetitions of words or
Orientation Phase phrases that are similar in sound but in no
Establish rapport and develop trust (first few days) other way
Establish a contract, define goals – set a sched of Flight of ideas- rapid shifting from one
meetings topic to another, with train of thought; a
Prepare to mention termination of a relationship – constant flow of speech in which the
prevent separation anxiety individual jumps from one topic to another
Major task: develop a mutually acceptable in rapid succession; Manic
contract Looseness of associations – Without
“I will meet you from 10 am-12 nn for 2 weeks” thought; Schizophrenic; free-flowing
Working Phase thoughts that seem to have little or no
Promotes acceptance, expression of feelings connection to one another
Promotes coping mechanisms Neologisms- coining of new words; newly
Inc. Independence invented words, having no public,
Major Task: identification and resolution of the pt consensual meaning
problems Thought blocking – suddenly stopping in
Anything related to pt problems; Identify; the stream of thought for no apparent reason,
resolve/interventions with no recall of the topic
Termination Phase Word Salad – mixture of incomprehensible
Summarize, evaluate outcome thoughts; an incoherent, incomprehensible
Gradual weaning process mixture of words, phrases, consisting of
both real and imaginary terms
*Nrsg Dx: Alteration in thought process -Voluntary- want to discharge = YES but there’s a
Thought Content grace period 48-72 hours reassessment with MD;
Delusions of grandeur – fix false belief; Good-OK; Bad- No involuntary commitment status
DO NOT encourage verbalization of -Involuntary- Client poses a threat to himself and
feelings, far from reality, resistant to others, with informed consent and refusal to
logic/reason; inflated sense of self appraisal treatment, if disruptive we can give a medication
Delusions of persecution – common among within 24 hours
paranoid schizophrenic All pts rights are retained except for the right to leave
*Nrsg Dx: Alteration in thought content the Institution.
If no senses are involved- disturbance in Phone Call privileges are remove if the client
thought and thinking exhibits harm to self and others – needs Dr’s order or
court order
f. Abnormal Motor Behaviors
a. Echolalia- inner compulsion to repeat other Anxiety- subjective feeling of apprehension, dread, or
people’s words impending doom
b. Echopraxia – repeat another people’s action - Cause:
c. Waxy flexibility – the pt possibly allows 1. Endogenous- within, biological or
examiner to move his limbs neurochemical, brain structure is the problem/
imbalances of the brain; Gamma Amino Butyric
Modes of care Acid (GABA) -inhibitory neurotransmitter
Milieu Therapy – envi. Modification/most effective: 2. Exogenous – cause is environmental
drug/subs abusers, rape; remove pt in the same envi.; 3. Psychodynamic – ineffective coping mech.
anxious, suicidal - Levels of Anxiety
Psychotherapy – focus on exploring past childhood 1. Mild – inc. focus; NI: acceptance & continue freq
experience & how this affect present behavior monitoring
Behavior modification – focus changing current 2. Moderate – dec. focus; NI: encourage
behavior without exploring the past thru verbalization of feelings, relaxation tech
reinforcement and punishment 3. Severe – no focus; therapeutic silence, PRIO:
Cognitive Therapy- focus on the pts thoughts and safety
how it affect feelings = actions/behavior = 4. Panic- no focus; PRIO: safety; stay silent; simple
consequence/consciousness; Anxious- teach pt instructions; stay with the pt; stay calm; element
relaxation tech thru guided imagery or deep breathing of fear to a specific stimulus
exercise; Depressed pt; Alzheimer’s- reminiscence - Mgt:
therapy 1. Provide safety
Group development/ Group therapy - 8-10 2. Assist in minimizing the pts anxiety-deep
members with same condition; #1 goal provide breathing
acceptance & support (al-anonymous-for the 3. Encourage verbalization of feelings
alcoholics, al-anon-wife, al-a-teen-children) 4. Pharmacotherapy - anxiolytics
5. Psychotherapy
6. Milieu therapy
7. Behavior modifications
Psychiatric Disorders
Classified in Diagnostic & Statistical manual for Anxiety Disorders
mental disorders (DSM-V) that are most likely to - Recapturing of anxiety – provoking stimulus = re-
appear on the NCLEX-RX awakening of unwanted thoughts, feelings,
Admission to mental health institution could be experiences from the past memory
voluntary or involuntary 1. Phobia- irrational fear – specific;
Cibophobia- fear with food
Agoraphobia – open spaces Rape
Mgt: Violence
- Provide acceptance Natural disaster
- Teach relaxation tech S/Sx:
- Therapy – Systemic desensitization- gradual Detachment
Gen. Anxiety Panic Emotional numbness exaggerated startled response
Disorder Disorder Anxiety & anger outburst
Onset Chronic Acute
Depression
Duration >3 mons 10 min/episode
Gen. description Excessive Fear of going Sleep disturbances (insomnia, nightmares, flashbacks-
worrying about crazy whenever we get bad experiences it gets frozen in the
daily concerns
brain)
Hypervigilance
S/Sx
Mgt:
Paresthesia
- Be non-judgmental
A feeling of choking for no reason
- Encouraged verbalization of feelings
N/V
- Assist pt in developing adaptive coping mech and in
chIlls
understanding association between feelings &
Chest pain
traumatic event
- Therapy: CBT (cognitive behavioral therapy),
Mgt is same with anxiety
Psychoanalytic
- Support group with help
OCPD – no rituals, rigid personality; they lack insight of
what their problems is
Mood disorders
OCD
Bipolar Disorder – characterized by episodes of mania
- Obsessive – thoughts
and depression with periods of normal mood and activity
- Compulsion- Actions
in between
- With rituals
- Manic-depressive
- Insight/awareness
- Cause:
- Prob: Control of urges
- Biologic - Norepinephrine – excitatory neurotrans
- Prob: Activity itself
Serotonin
- Time consuming
Intracellular Na+ - DOC – lithium
- Physiological need is affected
-Psychodynamic – massive denial; faulty family
- Mgt:
dynamics (chaotic)
- Initially provide time for rituals
- Activity: gardening, lawnmowing, finger painting,
- Ensure physiological needs met
delivery linens, NO sewing
- Working phase- explain changes in routine (set
- Non- competitive activity
limits) dec freq. and time
- requiring low concentration
- Reinforce the non-ritualistic behavior
- Nrsg Considerations:
- Assist the client in connecting thoughts, feelings
Restless/hyperactive
associated with behavior
Flight of ideas – refocusing
- Other mgt same with anxiety
Irritable/manipulative/demanding: set limits – a
Trauma and stressor-related disorders
matter of fact manner, just restate the fact/rules
2 types
immediately after it has been violated
1. PTSD - > 1 mon
Delusion of grandeur
2. ASD (Acute stress disorders) - < 1 mon
Unable to sleep – envi- non- stimulating, provide
rest periods, assist with warm bath, soothing music
Risk factor:
Offer: Diet: Inc Ca+ and Inc CHON – finger
War
foods, cheese burger, drink: milkshake
Accident
Mania Points to remember:

Hypomania A client with depression is preoccupied, has dec.
NO MOOD energy, and often even simple decisions – mgt. make
Mild depression simple decisions for the pt “It’s time for you to eat”
Major depression A person’s feeling of self-worth is generally
determined by accomplishments- ensure physiological
Depression needs met; assist ADL’s; Activity: Simple;
- Affects feeling, thoughts and behaviors Acknowledge simple accomplishments to inc self-
- Cause: worth “I’ve notice you take a bath today”
Biological: Norepinephrine As a client with major depression begins to feel better,
Serotonin the client may have enough energy to carry out suicide
MAO – inhibitory neurotrans. attempt – WOF: sudden inc. in energy upon taking
DOC- MAOI meds/antidepressants
Psychodynamic- general feeling and sense of
worthlessness Neurocognitive Disorders
-affects consciousness, memory, orientation, attention,
Specifics of Depression: perception
- WOF: Suicidal ideation -TYPES:
1. Major Depression (2 wks) Vs Dysthymia (chronic a. Delirium – ICU psychosis – manifestation of
last 2 yrs, Chronic feeling of dec. self-esteem, Poor hallucination; usually elderly in ICU
concentration, Depressed mood) b. Dementia – not reversible, generally intellectual
2. Involutional Melancholia deterioration
S/Sx:
Guilt – excessive, inappropriate Criteria Delirium Dementia
Psychomotor retardation Onset Acute Insidious, gradual
Cause: infection and
Older adults trauma
Early morning awakening Course Fluctuating during Stable overtime
the day
Significant wt loss/anorexia
Duration Short term, <1 Long term
Anhedonia month
Depression worse in the morning Consciousness Dec. Clear
Alertness Impaired, Abnormal Normal
3. Peripartum Depression Attention Dec Normal
- During preg or within 30 days postpartum depression- Orientation Impaired Impaired
prone to psychosis Memory Recent- impaired Impaired-recent then
remote
- RITA- Inc. Risk postpartum dep, irritable, tearful, Mgt Treat the cause Maintain optimum
anxious level of functioning
4. Seasonal Affective Disorder (SAD)- lifetime Dementia of Alzheimer’s type
Aka: winter/fall depression - Degeneration and atrophy of brain cortex
Occurs: during winter/rainy days - Dec. Acetylcholine – inhibitory
Cause: absence of natural light - Neurofibrillary tangles, neurotic plaques
Mgt: Phototherapy, spotlight, well lighted room - Assessment: A4’s
Assessment: at least 5 of the ff: Amnesia/forgetfulness
1. Sadness Aphasia/Speech impairment(expressive/receptive)
2. Loss of interest Agnosia- inability to recognize object/person
3. Worthlessness/hopelessness/low self-esteem Apraxia – inability to execute learn purposeful
4. Psychomotor retardation/agitation movements
5. Somatic manifestation - Stages:
6. Recurrent thought of death a. Mild- forgetfulness is the hallmark
b. Moderate – confusion, disorientation Cluster C- anxious/fearful
- 3As Apraxia, Agnosia, Aphasia a. Dependent – clingy; lack of self-confidence; looking
c. Severe – Personality and emotional changes for dominant partner
- Deterioration in all areas of function b. Obsessive-Compulsive – perfectionist, rigid; order in
- Sundowning Phenomenon – inc. disorientation expense of efficiency & flexibility
during sundown, OK= lighting, close the curtain, c. Avoidant – pre-occupied with being criticized
soothing music/radio // NO- TV
- Nrsg. Intervention: Principles of Nrsg Care:
- Pt wander – take hand & lead the pt back home Consistency – specially with anti-social disorder
- Lock the facility Limit setting – help develop trust, firm & consistent,
- Pt wanders from facility – follow the pt & redirect emotional support
@ safe distance, assess if pt can follow order if pt Treatment Plan – role Playing/Group therapy
cannot then reinforcement is needed - Assertiveness training – for avoidant & aggressive
- Wandering bracelet - Medications- Anti-depressants
- Check medical order
- *add note_ Alzheimer- neurotic plaques Eating disorders
Personality Disorders A. Anorexia Nervosa – self-employed
- Rigid maladaptive, causing significant personal starvation/perfection
distress and impaired social functioning Etiology-
- Causes: 1. Biologic – Inc. Serotonin
a. Genetic factors – hereditary predisposition 2. Developmental factors
b. Temperament factors – innate/inborn 3. Social factor- adolescence, over demanding
c. Biologic factors – ass. with depression parents
d. Psychoanalytic factors – rejecting, hostile, Personality Type: Achiever, perfectionist, female,
neglectful type of environment adolescent
S/Sx:
Personality- integration of the systems and habits that Amenorrhea- within 3 consecutive months
represent an individual No appetite
- Expressed through behavior Obvious wt loss
- Everyone is unique Reducing ideation of perfection
Emaciated- extreme muscle loss-cachexia
Cluster A -odd/eccentric behavior Xerostomia- dry mouth
a. Paranoid – extreme mistrust & suspiciousness Image disturbance – Initial Dx
b. Schizoid – withdrawn, cold, introvert Abnormal har growth
c. Schizotypal – similar to schizoid + delusions, Other Mx:
perceptual distortions Restricting calorie intake
Intense fear of gaining wt
Cluster B – emotional/dramatic Decreased VS
a. Narcissistic- self-loving, loves to be admired and Fluid & electrolyte imbalance
praise; lack remorse (same antisocial); grandiosity Criteria for hospitalization:
b. Histrionic – attention seeker; extrovert; manipulative Failure to gain weight in an OPD setting
c. Borderline – “psychotic-neurotic” “all good and all Loss of 30% of body weight within 6 months
bad”; splitting behavior, fears separation, impulsive, Fluid and electrolyte imbalance
unstable relationship (hallmark)- shift one job to WOF: Hypokalemia- cardiac dysrhythmias
another or labile mood; suicidal ideation Dec V/S: temp < 36°C, BP systolic <70 mmHg,
d. Antisocial – violate rules and laws, lack the sense of PR dec 40 bpm
guilt, PRIO- SAFETY – set limits
Mgt:
Re-establish appropriate eating behavior- set limits Positive Sx Negative Sx
with eating time: within 30 mins, sit with pt 1-2 hours -bizarre, additional feature Withdrawn, missing
Delusions Alogia-poverty of speech
after meal, pt wt- 2-3x/wk, wt goal: 3-5 lbs/wk Hallucinations Anhedonia – No pleasure
Disorganized speech Avolition – NO motivation
Insomnia Anergia- No energy
Bulimia Nervosa Grandiosity Asocial – same autism
- Binge eating followed by vomiting Illusion – inappropriate affect Inattention- No attention
- Etiology Catatonia Flat affect
Biologic Dec Serotonin General Intervention:
Psychodynamic- ambivalence with low self-esteem; 1. Acceptance
chaotic & broken family 2. Trust – firm & consistent
- S/Sx: 3. Present reality
Binge eating 4. Acknowledge feelings
Uses purging 5. Withdrawn pts- 1:1
Laxative and diuretic abuse 6. Assist ADL’s
Induces vomiting 7. Suspicious pts – develop trust, maintain eye
Metabolic alkalosis contact
I (extensive caries) 8. Disruptive – safety & set limits
Chipmunk face and callus formation (swollen *restraints –
parotid) Renewal hours/order: every 4 hours
Slightly below or above normal weight Expiry of order – every 24 hours
- Other manifestations Check V/S: every 15 mins
Under strict dieting or vigorous exercise Remove: every 2 hours for 10-15 mins
Loss of tooth enamel/tooth decay
Esophageal Varices- bleeding/aspiration Somatic symptoms and other related disorders
- Mgt: - Persistent worry or complaints about physical illness
Set limits without supporting physical findings.
Improve self-esteem 1. Conversion DO – physical Sx or deficit suggesting
loss or altered body function
Schizophrenia - Usually voluntary movement (ex. Conversion
- Split mind (Bleuler) blindness, possible limb paralysis, selective
- Disharmony between the pts thinking, feeling and mutism)
actions - Underlying cause: Trauma, overuse of denial
- Theories of Causation - They do not seek immediate treatment – labile
Biologic – Inc Dopamine in most part of the brain indifference
(+) Sx - Not faking Sx; Do not ignore the client just the
- Dec. Dopamine- (pre-frontal cortex) – CEO condition
(-) Sx secondary to meds - Curable
Psychologic theory- general vulnerability to
stressors of life - Goals of Treatment:
Family theory – rejecting hostile neglectful family - Make client functional as his condition will
environment allow to improve the quality of life
- General Mx: (DSM V) – deterioration of personality - To relieve Sx: initially- assess the complaint;
a. Delusion once admitted: ignore the condition but not
b. Hallucination the pt.
c. Disorganized speech – ass. looseness - If the pt talks about the condition, listen
d. Catatonic behavior- disorganized mov’t/action shortly but learn to redirect the topic
e. Negative Sx
2. Factitious DO physical or psychological readjustment; tolerance
- Munchausen Syndrome – need to increase the dose in order to get the same
- Impose on self effect
- Gain attention & emotional support
- Fake Sx (medical/psychological) Stimulant VS Depressant
- Alter medical Hx, specimen, result Intoxication Substance Withdrawal
- Claim that they are sick Inc/ upper Stimulant Decrease
- They inflict pain or injury Dec/Downer Depressant Upper
- Cause: unknown
- Treatment: CBT, psychoanalysis; Be non- Alcoholism – chronic disease or disorder, excessive
judgmental; Acceptance; Trust alcohol intake & interference in the individual’s health,
- Munchausen Syndrome by proxy interpersonal relationship and economic functioning
- Impose on others (WHO); depressants
- Malingering - Etiology
- external reward/incentive ex. Freedom fr Psychodynamic – oral fixation
liability Biologic – Dec Serotonin/hereditary
- needs legal intervention Behavioral- exhibit dependence, mistrust, feelings of
- Caregiver is overly attentive/concern inferiority, more phobic
- Hx of many hospitalization of the child - Detecting Alcoholism
- Improvement of child’s condition in the a. Blood alcohol level (BAL)
hospital but Sx recur when the child returns BAL S/Sx
Up to 0.05% Loss of inhibition
home Up to 0.1% Anxiety relief, euphoria, loud speech
- Labs & other Dx results do not match to Sx *0.1-0.15% Legal intoxication, slurred speech, motor
- Drugs/chemicals (child’s urine & blood intoxication, moodiness
0.2-0.3% Irritability, tremor, ataxia, may have memory lapse
sample) (blackout)
- Common victim- <6 yo 0.3% and up Unconsciousness
- Perpetrator: mother or primary health care
giver “mother imposturing” b. CAGE Questionnaire
C- have you ever felt the need to CUT down drinking/drug
Substance related, and Addictive DO use?
Substance Use DO – a cluster of cognitive, behavioral, A- Annoyed at criticism?
and physiological Sx indicating that the individual G-Guilty about something done?
continues using the substance despite significant substance E-Eye opener
related problems
Criteria: Goals for Detox
1. Impaired control over substance – takes substance - Remove inc. toxins in blood
in a larger amount - Dec. craving
- Reports multiple unsuccessful efforts to
discontinue use S/Sx: antabuse –how long? – as long as alcohol detected
- Craving Inc. HR
2. Social Impairment- problems with family, Severe headache
occupational and social relationships Flushes/hot flushes
3. Risky use of substance – hazard; continuous use of Tremors
substance despite physical or psychological Mgt.: do not drink alcohol 24°before the 1st dose, 2 wks
problems post last dose
4. Pharmacological Criteria – withdrawal- Avoid: flagyl/metronidazole- because it contains benzyl
physiological response due to abrupt alcohol (preservative)
discontinuation of substance use that leads to
Mgt.: Hydromorphone
Oxycodone
a. Short-term: DETOXIFICATION Methadone
- Mark the abrupt discontinuation of the subs; C.Hallucinogen
liver- natural detox LSD (lysergic acid Dilated pupils-all Visual disturbances
diethylamide) stim. or flashbacks
- Approximately 7-10 days PCP-phencyclidine Hallucinations Hallucinations
- PRIO- when was your last drink? Mescaline(peyote) Inc. V/S
Psylocibin-
Stage Timing Withdrawal S/Sx mushroom
1 6-8 hrs after last Tremors, sweating, agitation, GI D.Cannabinoid
drink Mx, (excitability) Marijuana (stim.) Weight gain Lack of appetite
2 8-12 hrs Stage 1 + hallucination Blood shot eyes Depressed mood
3 2-3 days Stage 2 + seizure Headache
4 2-5 days (worst) Delirium tremens extreme CNS
irritability associated with alcohol
withdrawal Neurodevelopmental DO
Mgt: seizure prec; anxiolytics- ADHD:
during detox; BP important – lead
to stroke - Attention deficit- PRIO
- ADD-adult
b. Long term: REHABILITATION -45 days - Main problems
1. Give up alcohol-abstinence; Disulfiram o Inattention
therapy or Aversion therapy o Hyperactive
Goal: to make drinking painful; milieu therapy o Impulsive
2. Live a positive lifestyle - More common in boys- onset until 12 yo
Rehab goal: change of behavior thru Group - Cause: Biochemical factors- dysregulation of
therapy (alcoholic anonymous) norepinephrine & serotonin
Al-anon- wife o Biological factors – frontal lobe disfunction
Al-a-teen-for children (CEO- executive function of the brain)
- Mx:
Commonly abuse substance - Poor decision making & impulsive control
Substance Physical Signs Withdrawal - Fidgets with hands and feet or squirms in the seat
effects - Easily distracted with external or internal stimuli
A.Stimulants - Difficulty in following instructions
Amphetamine Hyperactivity Depression
(shabu) Euphoria Irritability - Poor attention span
Inc. vs Wt loss Psychosis - Shifting from one uncompleted activity to another
Loss of appetite
Cocaine-route Perforated nasal Psychomotor
- Talking excessively
inhale septum Seizure - Interrupting or intruding on others
MI or respi arrest- - Engaging in physically dangerous activities
hyperstimulation of
heart and lung without considering the possible consequences
muscles - Mgt:
B.Narcotics/opiates
-downers
- Limit setting
-anticonvulsant - Re-channeling off energy
-Heroin PinpOint pupils Runny nose - Safety
-Morphine Incoordination Impotence
Dec. V/S Piloerection - Set limits
-Codeine Drowsiness - Schedule
- Structure the envi.
Other downers - Prio Nrsg Dx.: RFI – impaired social instruction
Alcohol - DOC:
Barbiturates
Methylphenidate (Ritalin) – prolongs the attention
“Hero Mo Co but I span, Inc hyperactivity; CNS stimulant; Side effects:
let you down”
dec. appetite & sleep; headache, N/V, *growth
Opiates retardation; rapid, repetitive ticks,
- Do not give during hours of sleep/night Moderate/Imbecile 35/40- Trainable 3-8 (pre-
50-55 school)
- Before meals for better absorption
- If once a day before breakfast; 2x a day Severe/idiot 20/25- Needs close 0-3 (toddler)
before breakfast & lunch; 6 hours before 35/40 supervision
Profound Below Needs(complete) 0 (infant)
bedtime or around 4 pm 20-25 custodial care
Next DOC: Dexedrine & Strattera Domestic Abuse- report automatically if suspected
Child Abuse- maltreatment of child
Autism Spectrum DO Physical Sexual Emotional Neglect
- Developmental disorder characterized by impairment Lack of crying Difficulty Suicide Poor hygiene
Unexplained walking or attempt Inadequate wt
in communication skills, or the presence of stereo- injury @ sitting Learning gain
typed behavior, interest and activities, with associated different Pain or difficulty Constant
impairment in social isolation healing stages swelling of Speech fatigue
Bald spots genitals disorders- Inconsistent
- More common in boys and occurs before 18 usually Extreme Unwillingness selective school
diagnosed at 2 aggressiveness to change mutism attendance
or withdrawal clothes Mood changes Consistent
- Cause: biological factor Apprehensive Torn, stained Anxiety hunger
- Main problem: Impaired interpersonal functioning child- or bloody Depression Untreated
Mx: reluctance in underclothing illness
changing WOF: any
1. Impaired social interaction – prefer to be alone clothes for allegations
2. Impaired verbal communication – echolalia sports made by the
Fear of parents child with
(acceptance) Frozen sexual
3. May avoid eye contact but maintain eye contact to watchfulness concerns
establish communication
4. Disturbance in personal identity- call by name to Priority: all types of abuse
establish identity 1. Safety – remove the child
5. Repetitive actions – learn about their routine 2. Report- to the appropriate agency
6. Resist change Child/adult – child/adult protective service
7. Poor nutrition – be extra sensitive to their body Spouse- local enforcement agency
language/needs 3. Physiological needs met
8. Temper tantrums – head banging (provide helmet)
9. NO real fear of danger _ PRIO-safety, structure, Elderly Abuse- maltreatment to elders
support, consistency Mx.:
10. Apparent insensibility to pain a. Physical- inconsistent explanation to injuries
Mgt.: possible contractures, presence ulcers
1. Offer presence b. Neglect – poor hygiene
2. NO touching (may not want cuddling) c. Emotional abuse – fear, agitation, confusion
3. Activity: less demanding d. Economic Exploitation- child’s handles the pt
4. Inappropriate attachment to object – allow account; sign unable to pay bills; no
5. Be consistent knowledge about own expenses/finances
Intellectual disability (Mental retardation)
- Sub-average intellectual capacity Spousal Abuse (Battered wife syndrome)
- Develops before 18 - Cycle of domestic violence characterized by wife-
- IQ: below 70 beating by the husband, humiliation and other forms
- Cause: Biological factors: inherited of aggression
- Main problem: Inadequate mental functioning
- BWS cycle
Levels of Intellectual Disability 1. Tension building- verbal argumentation vices,
Level IQ Feature Mental age jealousy
Mild/moron 50/55- Educable 8-12 (school 2. Severe battery – physical contact
70 age)
Trigger – NONE crisis- affect whole community; less severe –
DM: displacement; projection uncontrolled crying, feelings of panic, crying-yelling;
3. Honeymoon – DM: undoing severe – threatens to harm self of other & become out
Mx/Common Cues of Partner Abuse of touch with reality – psychosis
1. Repeated vague Sx- freq. hospitalization Characteristics of crisis state
2. Unexplained injuries 1. Highly individualized
3. Flinching in the presence of spouse 2. Self-limiting- 4-6 wks, true crisis state
4. Suicidal thoughts 3. Also affects significant others
5. Continual efforts to keep partner from getting 4. Person is amenable to suggestions
angry
6. Lack of relationship Role of the nurse – more direct & active approach
Nrsg Interventions Primary objective – give guidance & support
1. Be non-judgmental Thera. Com: Focusing on the problem they can resolve
2. Ask directly if abuse is occurring
3. Acknowledge serious abuse- help gain insight Steps in Crisis Intervention:
4. Assist victim to assess internal strength 1. Assess the situation (resources)
5. Give victim list of resources *local crisis hotline 2. Assess pt to develop cognitive awareness
6. Don’t push the victim to leave abuser if not ready “where were you” “who are you with”
7. Help victim come up with safety plan/escape 3. Assist the pt. in managing feelings- deep breathing
Sample: in one bag put all important documents 4. Explore with the client the resources available “who
including child’s favorite toy are your relative that we can call”
Prio: 5. Assist the client with the action plan
1. Remove from immediate physical danger
2. Report to local engagement agency Loss and grief- Normal reaction to real or anticipated
3. Provide local crisis hotline loss
Duration: 12-24 months
Rape Types:
- Sexual act with penile penetration 1. Anticipatory- occurs before loss
- Without consent 2. Disenfranchised – loss is experienced but it cannot
- Truths about rape: be acknowledged
1. Is an act of violence 3. Dysfunctional – prolonged emotional instability
2. Act of domination and power
3. There are more females raped than male Interventions:
4. There is more acquaintance rape done - Allow adaptive denial (DABDA)
- Rape trauma syndrome - Explore the clients perception & meaning of loss
a. Acute phase – immediately post rape- last 4 wks; - Encourage the client to examine the coping patterns
denial, silent, withdrawn; Sit with pt, secure in the past & present situations of loss
consent to assess injury, Thera: silence - Encourage pt to care for self
b. Outward adjustment- pt begins to verbalize
Mgt: encourage further verbalization End of life
c. Resolution – pt begins to accept – unacceptance= 1. Ethical & legal concerns
sexual dysfunction = frigidity = sexual a. Living will/advanced directives- pt decides for
promiscuity his further treatment plan, Last will- properties
Mgt: refer to psychotherapy b. Durable Power of attorney – pt assigns a
health care proxy to decide for his treatment is
Crisis case pt is incapable
- Critical incident – experienced, witnessed, learned 2. Hospice Care – terminally ill; 6 months to live
about = stress (coping OK; if unmanaged trauma) = RN- pain mgt and supportive care- expertise
*GOAL: to make the pt more comfortable Acknowledge: how difficult & painful the loses must be
3. Post mortem care Assess: method
Maintain dignity Ask: give immediate solution; ideas; if anyone is with the
Organ donor: Driver’s license- if wife won’t caller; ask the significant other to help the caller
permit, honor wife’s request cause everything Refer: walk in crisis
expires if pt dies not unless there is a Living will Refuse: give the tell # of the crisis center
Respect rituals
Thera com: silence and touch Electroconvulsive Therapy
Establish privacy - If the pt does not respond to medications
Maintain respect - Indications:
Suicide 1. Severely depressed not responding to meds
- Anger turned inwards 2. Acutely suicidal
- Ultimate for of self-destruction 3. Catatonic, manic
- Cry for help - Contraindications
- Who are these? CVA
Depressed Brain tumor
Hallucinating Inc ICP
Borderline personality Spinal cord injury
Client in crisis Glaucoma
Psychotic clients HTN, ischemia
Widowers/divorced CHF, angina
Terminally ill; recent job loss MI
- Nrsg. Interventions Renal & Liver dse
1. Assess for clues of suicide Pregnant
Valuables are given away Fracture
Living will change Active bleeding tendencies
Notes Fever/infection
Verbalization Pre Post
2. Conduct a lethality assessment Convulsive O2 100%
Oxygenate 100% Monitor- V/S esp RR
a. Plan- ask directly – are you planning on NPO- 6-8 hrs Effects: confusion, transient,
killing yourself> V/S every & post 15 mins ECT- mem loss, disorientation (Prio-
ONLY RN reorient)
b. Method- high-lethal= gunshot, jumping, Urinate first to prevent seizure Headache
poisoning; low lethal= med overdose, wrist induce incontinence
slashing Labs- ECG, EEG, x-ray,CBC
Secure complete PE
3. Keep the client safe Institute cardiopulmonary
- Remove sharp or harmful objects Clearance
IV route/heplock for meds NO
- Nurse pt ratio 1:1 IVF
- Suicidal- no harm or no suicide contract – not Pre-meds
legal to write notes Atropine SO4 – dec
serotonin
- Check pt in varying time to avoid Anesthetic short acting
predictability or every 5-10 mins = low barbiturates
Brebital (methohexital)
- Stay with the pt 24 hours round the clock = Succinylcholine (Anectine)
high – decseizure ep- NO paralysis
Psychopharmacology
Telephone triage: Suicide SNS PNS
Express: genuine concern & a desire to work with the -adrenergic -antiadrenergic
-anticholinergic -cholinergic (think of H2O)
caller NO water/dry -Inc secretion
Identify: name, address, and tell # Heart contractility Heart contractility
Cardiac output, blood sugar
Cardiac output, blood Diarrhea Orthostatic hypotension Instruct ct to rise slowly form a lying to
sugar Urinary incontinence a sitting position
Constipation (polyuria) Dermatologic Effects
Urinary retention Pupillary Constriction Photosensitivity Instruct the ct to wear protective
(oliguria) Bronchoconstriction sunscreens, clothing and sunglasses,
Pupillary dilation Teary, lacrimation and to limit exposure time in the sun
Bronchodilation Salivation Hormonal effects
NO tears/dry Dec. libido Explain that this may be transient
Dry mouth Inhibitory Amenorrhea Explain that this is reversible
Brain ✓ MAO Instruct ct not to discontinue the use of
Excitatory ✓ acetylcholine birth control as ovulation is continuing
✓ Norepinephrine ✓ GABA and pregnancy is possible
✓ Serotonin Weight gain Encourage proper diet and exercise
✓ Dopamine
✓ Acetylcholinesterase
General S/E
✓ Glutamine 1. Anticholinergic
Drugs for Schizophrenia 2. EPSE- Extrapyramidal S/E
-anti-psychotics Types:
Typical – dec. Positive Sx - Dyskinesia- difficulty controlling mov’t
Haloperidol (Haldol) – Inc EPSe – S/E - Pseudoparkinsonism- cogwheel rigidity, bradykinesia
Chlorpromazine (Thorazine) – WOF hypotension - Dsytonia – involuntary muscle spasm
Thioridazine (Mellaril) – orthostatic hypotension - Laryngeal pharyngeal constriction
Atypical – dec negative Sx - Oculogyric crisis
Clozapine (Clozaril) – dec WBC- WOF - Writer’s cramp
Agranulocytosis (fever, sore throat) - Torticollis (wry neck)
Olanzapine (Zyprexa) - Akathesia- restless
Risperidone (Risperdal) A/E
Seroquel (Quetiapine) NMS- Neurolyptic Malignant Syndrome
Aripiprazole (Ability) - Inc temp *** indication
- Dec LOC
Risperidone (Risperdal) - Muscle rigidity
1-2-3 regimen (1 OD / 2 BID/ 3 TID) - Tremors
Therapeutic range – 4-8 mg/day Antidote- Dantrolene- muscle relaxant, dec fever
Autism DOC
Insomnia Anti-depression
Suppress tardive dyskinesia “TCA” -tricyclic anti-depressants
Irreversible “3 cute girls mahilig sa Tofu”
Tongue protrusion Pamelor (nortriptyline)
Lip smacking (teeth grinding) Elavil (amitriptyline)
Anafranil (Clomipramine)
Side-effect Nrsg Intervention Tofranil (Imipramine)
Anticholinergic Sx WOF- cardiac dysrhythmias
Dry mouth Encourage frequent sips of H2O, good
oral hygiene, chew sugarless gum SSRI
Blurred vision Reassure pt of transient nature of “Pro taxil nagZOZOlo”
blurred vision
Prozac (Fluoxetine)
Retinitis pigmentosa Notify the dr; slow loss of vision lead
to blindness Zoloft (Sertraline)
Urinary retention or I&O, notify dr Paxil (Paroxetine)
hesitancy- kidney dys
Constipation High fiber, Inc OFI and exercise WOF: sexual dysfunction
Paralytic ileus- Notify dr.- surgery
obstruction/paralysis MAOI – drug interact with SSRI AVOID
small intestine
Sedation Client teaching regarding need to Parnate (tranylcypromine)
restrict driving or operation of Nardil (Phenelzine)
machinery
Marplan (Isocaboxacil)
Tyramine rich precursors so AVOID tyramine rich
foods: processed aged, pickled, smoked, overripe fruits A. Benzodiazepine- > S/E
NO banana and avocado// OK cottage cheese or cream - Alprazolam (xanax)
cheese - Diazepam (valium)
WOF: hypertensive crisis - Lorazepam (Ativan)
- Temazepam (Restoril)
Anti-depressants health teaching - Chlordiazepoxide (librium)
- NO smoking, alcohol, drug to drug interactions - Flurazepam (Dalmane)
- 1 at a time - Midazolam (Versed)
1st SSRI
2nd TCA B. Nonbenzodiazepine < S/E
3rd MAOI - Buspirone (BuSpar)
- Buproprion or novel (well butrin) – anti-depressants - Zolpidem (Ambien)
without category new; instead of SSRI Medications to treat Alzheimer’s Dse
- Wait 2-4 wks before you introduce another -inhibits acetylcholinesterase
antidepressant -Ex. Donepezil (Aricept)
Drugs for Mania Tacrine (Cognex) – toxic -liver
Level- 0.6-1.2 meq; weekly checking of blood level -S/E
Increase urinary output-polyuria “Do not pisil”
Toxic-coarse hand tremors (mild) -active bleeding tendency
Hands -fine hand tremors (N S/E) Toxic liver
Inc OFI-2-3 L/day -expected polydipsia Comfort
Uu- Normal mild diarrhea – toxic-diarrhea Room visits (polyuria, incontinence)
Maintain-regular Na intake – 3g/day Impaired Sphincter control
N/V
Lithium- NO antidote Anorexia
Therapeutic Mild Moderate Severe Alcoholism - dec serotonin
serum level Toxicity Toxicity (>3meq/L) Alzheimer – dec. acetylcholine
(1.5-2) (2-3 Anxiety – dec GABA
meq/L) Depression – dec Norep/ser and Inc MAO
Fine hand Diarrhea Ataxia Seizure
tremors Vomiting Tinnitus Organ failure Manic – Inc. Norep/ ser/ intracellular Na+
Mild diarrhea Drowsiness Blurred vision Renal failure Anorexia – Inc. serotonin
Goiter Dizziness Delirium Coma
Anorexia Coarse hard Nystagmus Death Bulimia nervosa – dec. serotonin
Edema tremor
Wt gain Muscular
Polydipsia weakness Pediatric Nursing
Polyuria Dry mouth
Lack of Developmental Levels
coordination Infants: 0-18 months
Tip Erickson – Trust vs Mistrust
Cause: SNS Tx Goal to Gen. S/E Freud- Oral phase – oral gratification
Norepinephrine PNS Jean Piaget – sensory motor learning – hearing
Serotonin Solitary play – they play with their body and senses
Intracellular Na+ Toys: mobiles (visual), rattles, teething rings (teeth
Anti-anxiety/Anxiolytics erupt 6 months), music boxes & squeeze toys, floating
- Major use to reduce anxiety, also induce sedation, bath toys
inhibit convulsion Significant others – mother
- Do not modify psychotic behavior Fear- Stranger anxiety – manifestation: crying
- S/E: drowsiness, mental confusion Accident/Injury: Aspiration, fall
- Next DOC: Carbamazepine Concept death: none
Hospitalization: Oral stimulation & sucking/BF Accident/Injury: MVA
Surgery: pacifier Concept death: temporary and reversible
Hospitalization: explain using puppets and dolls
Toddler: 18 months – 3 yo
Erickson – Autonomy- if met with self-control; over- School Age: 6-12 yo
depressed easily vs Shame and Doubt – impulsive or too Erickson – Industry (met: competent in doing
dependent or independent activity, attempting to learn) vs Inferiority (inferiority
Freud- Anal phase; elimination – toilet training starts complex- manifested by poor performances)
18 months- signs – baby is able to walk, talk and sit; 3 Freud- Latency – sudden dec energy = focus on
developmental task (1) there must be a control of learning/activities
sphincters as evidence by walking (2) cognitive Jean Piaget – concrete
understanding of what it means to void- empty the Competitive play – base on competence, collective,
bladder (3) must have the desire cooperative, Achievement oriented
Jean Piaget – pre-operational Toys: card games, scrabble (board games), skipping
Parallel play – no interaction ropes, sport toys
Significant others – parents Significant others – Teacher
Fear- separation-crying Behaviors to observe: achievement oriented
Ego-centrism Fear- doing wrong
Accident/Injury: (1) falling (2) poison (3) burns, Accident/Injury: MVA
thermal Concept death: irreversible
Toys push and pull, talking toy cordless telephone, Hospitalization: can appreciate simple charts &
blocks, board book with large pictures; Criteria: (1) safe diagram
(2) purpose/goal- teach them to walk & talk
Concept death: reversible, temporarily Adolescent: 12-20 yo
Hospitalization: security objects to dec anxiety Erickson – Identity (emotional stability; good
Behaviors to observe: interpersonal relationship) vs Role Confusion (poor
a. Negativism “no”, Mgt. (1) Offer choices, handling of emotion, poor interaction & short-term
types of foods; utensils places: clothing relationship, love is express thru sex)
; (2) Set limits by repetition & be firm Freud- genital; sudden inc. libido; sexual genital
b. Temper tantrums – expression of their need maturity – puberty – inc. hormones
Mgt: (1) ignore as long as safe (2) set limits Jean Piaget – formal
(3) time-out – remove from the scene and Fore play/courtship
discipline, face the wall, minimum of 3 mins. Significant others – peers
or as long as the age of the child 1yr=1min Fear- body image disturbance
Accident/Injury: Sports accident, Substance abuse
Pre-school: 3 yrs – 6 yrs, “why” (drugs & alcohol), suicide, sexual abuse
Erickson – initiative vs guilt - exploration Hospitalization: Provide privacy; let same gender
Freud- phallic stage – some genital dev, Inc Libido, assist; body diagrams; involve them in decision making
have sexuality awareness; 2 complexes = Oedipal -sOn Rapid growth with companion; Body changes which
to mother, Electra- daughter to father corresponds to puberty, moody & unpredictable, attempts
Jean Piaget – pre-operational to make decisions for himself/herself; make long range
Associative/cooperative play: loves to share and plans for the future.
imitate adults into play Developmental Milestone
Toys: role playing games – play school, play house, Fine Motor Skills- Proximo-distal
doctor-nurse kit, hand puppets, paper dolls Months
Significant others – immediate family 0 – Reflex grasp
Fear- Body mutilation, castration, pain 3 – Hands held open with palmar grasp
hospitalization “white coat fear” 6 – Palmar grasp starts to disappear
9 – Pincer grasp (fingers) Physiologic loss of weight a couple of weeks after birth
10 – Points at object will be observed – 5-10% weight loss, length 1 yr – 50 %
11 – Puts objects in a cup inc
12- Throws an object/2 blocks build Rapid stages: infancy & adolescents
Years Slow periods: toddler, preschool & school age
2 - 5 blocks Reminders: birth weight
2 ½ - 7-8 blocks 2x the weight: 6 months
3 – unbutton shirt 3x the weight: 12 months
4 – buttons up 4x the weight: 24 months
6 – tie shoe lace
Gross Motor Skills – cephalocaudal development Nutrition Principles
Months 0-6 – exclusive breast feeding
0 – head lag 4 months – dec. iron stores
2 – lift head Post 6 months – supplementary feeding
4 – full head control 1. Cereals
5 – roll over 2. Fruits
6 – sit with support
3. Vegetables
7 – foot to mouth
4. Meats
8 – sit without support
9 – crawl 12 months – 1. Yolk – more nutritious
10 – stand with support 2. White – contains most allergens
11 – cruising 12-13 months infants start to drink cup
12 - stand without support To wean off from bottle
14-15 – walk Prevent dental carries
3 yrs – ride a tricycle 1 month – 1 tooth
Introduce food 1 at a time:
sit with sit without Interval 5-7 days to monitor for tolerance and allergy
support support Offer food – serving size – 1-2 tsp only
Feeding Problem:
Infancy – aspiration
Toddler – physiologic anorexia
stand with stand without Preschool – picky eaters; food pads
support support School – 0 cal intake (junk foods)
Adolescence – anorexia nervosa (disorder)
2 Notes on immunization:
General Contraindication & Precaution
Anaphylactic Reaction
Smile Live vaccine – immunocompromised, pregnant, allergy to
0 – may smile eggs & gelatin (derives from eggs) which serves as
1-2 months- coos, social smile nutrition/food for bacteria
2-4 months – laughs, makes consonant sounds Moderate to severe illness
6 months – imitative sounds
8-9 months – pronounces syllables (da-da)
12 months – says 4-5 words
2 years – first phrase, 300 words
2 ½ years knows first name
3 years – 3-4 words sentences, 900 words
Growth Principles
4. Hib: Haemophilus Influenzae B --CO2--
Pneumonia & epiglottitis (cause respi depression)
- Route: IM
5. PCV: Pneumococcal Conjugate Vaccine
- Route: IM
- Prevents: pneumonia; meningitis (2° to
pneumonia)
6. IPV – Inactivated Polio Vaccine
- Route: IM/SubQ
- CI: allergy to streptomycin, neomycin,
gentamycin, formalin(preserve)
7. MMR – Measles (Rubeola), Mumps, Rubella
(German measles)
- Route: SubQ
- Avoids: allergy to eggs and gelatin
- If the child receives Ig – HOLD MMR for 3-6
months
8. Varicella – Prevents chicken pox & herpes zoster
- Route: SubQ
- Avoid – aspirin – leads to Reye’s syndrome –
swelling of the brain and liver tissue; even
common flu still leads to Reye’s syndrome
Reflexes – disappearing age – any delays cause neurologic

disorders
S – 3-4 months Reye’s Syndrome_viral/think about
T– 3-4 months liver failure_so inc. ammonia, inc
General S/E /Inflammatory Reaction
ICP; avoid aspirin, chicken pox
Swelling S– 4 months
Tenderness PM – 6 months
Erythema Ba – 12 months
Fever
1. Hepa B vaccine – if mother HbSAg + 1. Sucking/rooting reflex – dis 3-4 months
carrier/infected you have to clean to administer the 2. Tonic-neck/fencing reflex – dis 3-4 months
vaccine + Hep B Ig to the baby within 12 hours 3. Palmar grasp - 6 months
after birth 4. Startle reflex- 4 months, flexion of extremities
- test mom for HbSAg – HbSAg (?) – hep B Ig (protective mechanism)
ASAP 5. Moro reflex – 6 months, tilt head down @ least 30°-
- low birth weight – if baby is <2 kg hold the extension of upper extremities
vaccine 6. Babinski reflex- 12 months, normal fanning of toes
2. Rotavirus – cause AGE – severe DHN leads to once examiner stokes (J) the sole of the foot,
death Abnormal- for adult fanning, normally it should coil
- Oral route Birthmarks
- Withhold: n/v or diarrhea
3. DtaP – Diphtheria, Tetanus, acellular (without
nucleus of the cell in the vaccine) Pertussis
- Route: IM
- Comp: encephalopathy, seizure & high-grade
fever
1. Telangiectatic nevi (stork bite) - like rashes; Pale 2. Postmature > 40-42 weeks
pink or red, flat, dilated capillaries on eyelids, nose, S/Sx – signs of growth – long but thin (glycolysis-
lower occipital bone and nape of the neck; blanch muscle wasting)
easily; more noticeable during crying periods; Placenta is not viable at this period so related
disappear by age 2 yrs problems are malnutrition and fetal distress
Signs of malnutrition – dry cracking skin & DHN,
2. Nevus flammeus (port wine stain) – capillary no vernix & lanugo, long hair and nails, Alert look
angioma directly below epidermis; non-elevated, Assessment Problem
sharply demarcated, red to purple, dense areas of 1. Hypoxia – dec placental viability and dec. blood
capillaries, commonly appear on face, no fading flow, meconium
with time, may require future surgery, laser therapy 2. Hypoglycemia – Mgt: BF, D5 containing IVF,
is indicated glucose water- use feeding cup
3. Nevus vasculosus (strawberry mark) – capillary 3. Fetal Distress
hemangioma, raised, clearly delineated, dark red, 4. Meconium Aspiration – suction
with rough surface, common in the head region, No suctioning if NSVD
disappears by 7-9 years 5. Meconium Staining – bathing is required, oil
bath; Infection- IV antibiotics (gentamycin)
4. Mongolian spots – bluish black pigmentation on

lumbar dorsal area and buttocks, gradually face Pediatric Disorders
during the first and 2nd year of life, common in Asian Cardiovascular d/o
and dark-skinned individuals Congenital heart diseases
1. Acyanotic heart Defect –
The Risk Neonates direction of the defect is
1. Premature < 37 weeks Left to Right (no
- S/Sx: respi. Distress syndrome cyanosis) – increase blood
o Nasal flaring flow to the right side so there is a right ventricular
o Fast breathing hypertrophy & increase heart beat leading to
o Chest indrawing/grunting pulmonary hypertension then pulmonary congestion
o Chest retractions (CHF)
Complication is atelectasis cause dec. surfactant a. VSD (Ventricular Septal Defect) – there is an
- Mgt: opening in the right ventricle so increase blood
o ET flow to the RV
o O2 via Continuous Positive Air Pressure b. ASD (Atrial Septal Defect) – foramen of ovale
(CPAP) – promote gas exchange (normally closes 1 month
o Regulate body temperature – incubator after birth) still open
WOF: hypothermia leads to anaerobic which increases the blood
metabolic ---lactic acid – fetal distress flow to the RA
o Maintain nutrition – gavage feeding- So, for VSD & ASD –
orogastric tube (route), nasal breathing Dacron patch is use to cover the defect/hole
c. PDA (Patent Ductus Arteriosus) – Normally
closes @ 1 month of age/24 hours here it is still
1-5 yo – HOLD < 80 bpm
6-10 yo – HOLD < 70 bpm
>11 yo – HOLD < 60 bpm
- WOF: toxicity
Visual disturbances
Anorexia
N/V
Diarrhea
open so increase blood flow to the RA; connect Abdominal cramps
pulmonary artery (pulmonary congestion) & aorta b. Diuretics
c. ACE- inhibitors – dec. peripheral resistance
d. COA (Coarctation of Aorta) – narrowing, 2. Diet- dec. Na+
which causes 3. Dec. Cardiac O2 demand
pulmonary a. Cluster care – plan activity nursing care
congestion, increases b. Promote rest and sleep (PRIO)
BP (upper c. Emotional, social, mental rest
extremities) and d. Quiet play is encouraged, ex. Drawing
extremities) Cyanotic- Right to Left shunting
1. Transposition of the great vessels – displacement of
Diagnostic and Aorta & Pulmonary artery; no communication
Management for Acyanotic Heart Defects between systemic and pulmonary circulation that’s
*Chest Radiography why there is a cyanosis
*Echocardiography – 2D echo, somehow sound S/Sx: persistent cyanosis despite vigorous crying,
waves or UTZ of the heart Hypoxia despite of O2 therapy
- detect/measure pressure within chambers & measure Mgt: prostaglandin E1 (inc prostaglandin to keep
the ejection fractions (% of amount of blood pump PDA open allowing the mixture of UnO2 and O2
out within each chamber) blood); corrective heart surgery; arterial switch
*Cardiac Catherization (Dx & therapeutic
(immediate intervention)) - peripherally inserted
*Corrective Surgery
= Open heart surgery – induction of asystole to
prevent further injury; induction of hypothermia
leads to dec. metabolic rate then dec. heart rate then
dec. cardiac O2 demand or general O2 demand; use
of bypass machine – heart lung machine Before surgery Rule of 10
= Close heart surgery – Indomethacin (NSAIDS) – 10 lbs & 10 weeks
dec release of prostaglandin leadingIf to
it starts
PDA with
closes 2. Tetralogy of fallot
“T” it is trouble Varied Pics Of
Balloon tamponade – use cardiac catheter resolve Ventricular Septal defect
the Ranch
coarctation of aorta; sometimes stent dissolves 3 Pulmonic stenosis
months Overiding of Aorta
Medical & Nursing Mgt: Right ventricular hypertrophy
Goal: Prevent Congestion
1. Drugs
a. Digoxin (Digitalis), Lanoxin
- WOF: hypokalemia (inotropic) leads to
inc sensitivity, so inc. PABOWS
- WOF: bradycardia (chronotropic)
< 1 yo - HOLD < 100 bpm
S/Sx: Elevated erythrocyte sedimentation rate or
*exertional dyspnea positive C-reactive protein level- rel to
*tet spells – cyanosis during feeding/crying inflammation (might be generalized)
*clubbing of fingers – chronic hypoxia Prolonged R-R interval on electrocardiogram
*polycythemia (inc RBC) – compensatory mechanism, Note: for making a dx, 2 majors or 1 major and 2
some irregular shape minor manifestations must be accompanied by
*stranded physical growth delayed development supporting evidence of a preceding streptococcal
Mgt: infection (positive throat culture for group A
*dec. O2 demand streptococcus and an elevated or increasing
*Propanolol – dec. tet spells, cause vasodilation promote antistreptolysin o titer)
perfusion - Mgt: control joint pain and inflammation
*Monitor- Hgb & Inc Hct count - Bed rest
- polycythemia- inc RBC so concentrated blood - Antibiotics
then Inc Hct - Salicylates/ASA/aspirin WOF: A/E tinnitus
a. intervention of tet spells that confines circulation on - Seizure precaution
the vital organs - Antibiotic prophylaxis for dental work &
- squatting (older invasive problem
children)
- knee-chest position 2. Kawasaki Disease
(babies/infants) - An acute systemic inflammatory disease
b. O2 supplementation - Self-limiting for 4-8 weeks
c. Morphine – dec - Cause: unknown/autoimmune
catecholamines leads to - Most serious complication is Heart involvement
vasodilation and then dec.
anxiety
*Monitor activity intolerance
Surgery:
Palliative – Blalock- Taussig – subclavian artery
connected to pulmonary artery promoting blood flow to
the lungs
- Pathognomonic sign: Strawberry tongue
Complete: Brock procedure - repair of pulmonary
- S/Sx:
stenosis
a. Acute stage
Fever
Acquired Heart Disease
Conjunctival hyperemia- sore eyes
1. Rheumatic Heart Fever – an autoimmune dse that
Swollen hands, rash and lymph nodes
affects Connective tissues
enlargement
- It manifest 2-6 weeks after untreated GABHS
b. Subacute stage
infection of URT
Joint pain
- Dx jones criteria
Thrombolytics – inc platelet
Major Criteria:
Cracking lips
Carditis
Desquamation of skin on the tips of fingers
Arthralgia
and toes
Chorea
Cardiac manifestations – tachyarrhythmia
Erythema marginatum – redness by lines
c. Convalescent stage – child appears normal but
Subcutaneous nodules
signs of inflammatory may be present
Minor Criteria
Fever
Arthralgia
- Surgical care- prone/semi prone- drainage, ensures
airway clearance
- Observe: frequent swallowing (continuous/active
bleeding); airway problem – REFER!!! Immediately
- Protect: elbow restraint
- Feeding – sippy cup used
- Intervention: - Future problem – speech defect & dec. social
Assess: heart sounds acceptance
Examine the eyes for conjunctivitis
Monitor I&O 3. Tracheoesophageal Fistula
Diet: soft foods & liquids (dysphagia) - S/Sx: Choking, Coughing, Cyanosis
Passive range of motion exercises
Meds: Ig (IV), ASA *(Monitor for Reye’s Syn)
Kawasaki Dse
“do not try to buy a Kawasaki you might
CRASH and burn”
✓ Conjunctivitis
✓ Rashes - Surgery: thoracotomy with diversion & dilation of
✓ Adenopathy TEF
✓ Strawberry tongue
✓ Hand desquamation and feet 4. Pyloric stenosis
✓ Fever (burn) - S/Sx: abdominal distension
- Projectile vomiting (forceful abdominal
contraction)
Gastrointestinal Problems
- Metabolic alkalosis & Hypokalemia
1. Cleft lip
- Cause: multifunctional - Dx: String sign- olive shape mass (pathognomonic
- Common: males sign)
- Surgery: Cheiloplasty - Surgery: fredet-ramstedt procedure
- Consider age – 3-6 months- to preserve the (pyloromyotomy with pyloroplasty)
sucking reflex - Nrsg Consideration: Pre-pro- NPO, IVF; Post-pro.
- Surgical readiness: 10 weeks and 10 lbs Monitor I&O; small frequent feeding, feed infant
- Surgical care: position post op: Supine slowly, burping frequently
- Protect – Logan bar/bow (splint
suture)
- Future problem: speech defect
and dec. social acceptance
2. Cleft Palate
5. Intussusception
- Cause: hypervitaminosis
- Telescoping of the intestine
A (maternal)
- Cause: weak ileocecal valve
- Common: females
- S/Sx: spasmodic abdominal pain
- Surgery:
- Blood with mucus (currant jelly stool-self-
Uranoplasty/palatoplasty
digestion)
- Age: within 6-24
- Bile stained vomitus (greenish)
months- develop of speech organs, < 6 months –
- Sausage shape mass
possible resurgery, > 24 months – irreversible
- Dx: barium enema
- Mgt: Barium hydrostatic reduction technique –
push the intestine back, it can recur so just monitor 8. Celiac disease (Celiac Sprue)
- Intolerance to gluten
- Assessment
o Steatorrhea
o Anorexia
o Abdominal
pain
o Vomiting
o Anemia
6. Hirschsprung’s Disease (AKA Aganglionic o Muscle wasting
megacolon) - Celiac crisis- (Precipitating factors) an inc intake of
- Absence of ganglion cells (nerves that control gluten
peristalsis) in the large intestine, so if no ganglion - S/Sx: severe vomiting, watery diarrhea leads to
cells then dec. peristalsis and there will be severe DHN
accumulation of stool on the affected segment - Interventions:
(megacolon) so there will be constipation o gluten free diet
o minerals & vitamins supplements
o instruct parents to prevent celiac crisis
o Instruct parents about Celiac Sprue
Association
o Foods Allowed: meat such as beef, pork,
poultry, and fish, eggs, milk and dairy
- S/Sx: initial- absence of meconium (problem 24°post products, vegetables, fruits, rice, corn, gluten
birth) free flour, puffed rice, cornflakes, pre-cooked
- Constipation gluten free cereals
- Ribbon like stool- semi-liquid stool o Foods Prohibited: commercially prepared
- Pellet like stool ice cream, malted milk, prepared puddings
- Abdominal distension with possible fecaloid and grains, including anything made from
vomitus Barley, Rye, Oats, Wheat, breads, rolls,
- Weight loss cookies, cakes, crackers, cereal, spaghetti,
- Dx Procedure: rectal biopsy- if no ganglion cell (+) macaroni noodles, beer, and ale
- Barium enema – outline/contrast the large
intestine 9. Phenylketonuria
- Surgery- endorectal pull-through procedure - Phenylalanine – excess leads to mental retardation
- Permanent colostomy - Phenylalanine – converted to tyrosine by
- Nrsg Intervention: Bowel irrigation, laxatives, phenylalanine transferase enzyme– which is the
enema building block of neurotransmitters (S/Sx seizure and
- Diet: Inc. CHON, Inc. CHO & dec Fiber (inc the mental retardation), aids in digestion (malnutrition
bulk of the stool) and malabsorption), precursor for melanin (albinism)
- Phenylalanine – converted to phenylacetic acid –
7. Imperforated Anus urine causing green stain phenylketonuria
- S/Sx: initial sign: no meconium - Absence of the enzyme
- Cause: embryonic abnormality - Dx Procedure: Guthrie test – blood/urine test
- Surgery: anoplasty – ok to perform at birth, post - Intervention: Diet – lifelong diet modification, pt
procedure temporary colostomy, take down after 10 must avoid animal sources alternative tofu, soy,
months, before 18 months toilet training is still protein of high biologic value (vegetables), avoid
applicable milk, cheese, ice cream, nuts and beans
- Ok formula milk- lofenalac, milk without 2. Hydrocephalus:
phenylalanine
Neurologic disorders
Neural tube defects
1. Spina bifida
- Causes – maternal malnutrition, drug intake,
maternal Folic acid deficiency leads to embryonic - Causes: tumor (Non-com), hemorrhage
abnormality then non-closure of the neural tube (communicating), infection & trauma (both)
(normally closes 3-5 months with folic acid) - Types:
- Classification: o Communicating – inc in volume of
a. SB Occulta – hidden/not obvious/no CSF/problem in the drainage
outpouching; with thin hairlike substance o Non-communicating – obstruction in the flow
above the lesion, asymptomatic, no of CSF
treatment - S/Sx:
b. SB Cystica – cyst like; outpouching o S/Sx of inc ICP
o Sunset eyes
o Frontal bossing
o Dilated scalp veins (attempting to drain CSF)
o Inc head circumference (N 33-35 cm)
o Macewen’s sign – crack pot sound
99 o Initial Sign of inc ICP
- Meningocele – CSF only ▪ Restlessness
- Myelomeningocele – CSF & spinal ▪ Apprehension
cord ▪ Tachycardia
- General S/Sx – o Shunt prob:
- Flaccid paralysis – L1 & L5 ▪ Infant- high pitch/shrill cry
- Altered elimination pattern – neurogenic bladder ▪ Toddler – loss of appetite &
(bladder atony) – S1- S5, or constipation, fecal headache
incontinence ▪ Older children – altered LOC
- Head & neck rigidity (meningitis like Sx) - Nrsg care
- Surgery – closure of neural tube defect; suture o side lying position
muscle and fascia o measure the head circumference to monitor
- Mgt: prevent – infection, pressure & injury progress
- Intervention: o prevent up in ICP – infants- dec stimulation,
- Position: Prone limit suctioning, avoid Valsalva maneuver
- Feeding: hold the baby in the upper back and - Surgery: ventriculoperitoneal shunt – semi-
buttocks permeable
- Cover: sterile gauze moist with NSS to avoid o Pre-op – monitor I&O
drying/cracking ▪ Small frequent feeding
- Bowel Function: laxatives ▪ Reposition head frequently
- Monitor infection: meningitis o Post-op- position – flat on bed to avoid
- Provide adequate nutrition abrupt drainage (cause inc ICP- headache) for
- Monitor signs of inc ICP at least 24 hours
▪ Monitor for shunt malfunction
synonymous to inc ICP/ further inc
head circumference
- Mgt: Antibiotics – clindamycin, co-amoxiclav
3. Cerebral Palsy o Antipyretics
- Abnormality in the pyramidal tract – site of o Surgery – tonsillectomy – if recurring within
decussation, coordinates movement & sensation 6 months
- Impaired movement and posture o Pre-op – check dental and bleeding status
- Mental retardation o Post-op – position – side lying (semi-prone)
- Assessment to facilitate drainage
o Feeding difficulties ▪ Observe for bleeding – frequent
o Abnormal motor performance swallowing REFER!!!
o Stiff rigid arms & legs (atrophy & ▪ Prevent bleeding – cold application –
contractures) ice cooler or ice chips
o Delayed dev. Milestones ▪ Avoid: red colored juice, citrus,
o Persistent infantile reflexes milk, dark colored food, hot & warm,
o Abnormal posturing popcorn, chips, nuts; pointed objects
o Seizures ▪ Diet: food at room temperature, clear
- Nrsg Interventions: & non-irritating fluids
o Goal: early detection & prompt treatment Ex. Water, apple juice, popsicle
(neuron)
o Rehab 2. Laryngotracheobronchitis (LTB)/Croup
o Assess the child’s dev level - Cause: parainfluenza
o Mobilizing devices (wheelchair & wheel go virus (flu like)
cart) - S/Sx: hoarseness of
o Encourage communication & interaction voice
o Provide safety- inc risk for fall, raise side o Brassy,
rails all the time & ensure companion at all spasmodic, seal-
times like cough –
o Inc risk for pressure ulcer – turn them every 2 attack
hours & change diapers regularly o Inspiratory stridor – noisy breathing upon
inhalation
Respiratory Disorders o Fever
1. Tonsillitis - Mgt: Supportive care
- Lead to Rheumatic heart fever o Prevent coughing
- Part of the immune system; highly vascularize; has o Feed & hydrate with aspiration precaution
lymphatic vessels that directly drains into the heart o Dec O2 demand
- Cause: GABHS/ streptococcal infection o During attack – mist therapy (croup tent/care)
- S/Sx: Inc/high grade fever – body malaise ▪ Cold air- relaxes the airway (fog) –
o Cough cause vasoconstriction
o Sore throat
o Dysphagia 3. Epiglottitis
o Unpleasant mouth - Cause – haemophilus influenza
odor (pus) - Common – 2-5 yo
- Grading - S/Sx: Dysphagia
o (+) 1 / N – tonsil is located laterally & not o Drooling
red/swelling o Dyspnea – tripod
o (+) 2 – tonsil reached the midline positioning (sitting,
o (+) 3 – tonsils attached/closed to uvula leaning forward, arms at
o (+) 4/kissing tonsil – both are very much side supporting the upper
swollen/reach each other, needs intubation
body, open mouth and tongue out) Hematologic disorders
o Life threatening – examining throat with a 1. Hemophilia – x-linked recessive disorder;
tongue depressor increase risk for bleeding
- Mgt: emergency tracheostomy a. Type A – clotting factor VIII is lacking
o Antibiotics – Ceftriaxone (rocephin) b.Type B – clotting factor IX is missing
o Corticosteroids PRN - S/Sx – prolong bleeding
o O2 o Skin petechiae (bleeding capillaries)
o Obtaining nasopharyngeal culture o Hematoma
o Semi-fowler o Hemarthrosis (blood in joint spaces)
o Maintain inc humidity o Epistaxis
- Mgt: prevent – trauma – avoid contact sports
4. Cystic fibrosis/Mucoviscidosis – thick mucus (swimming), wear protective devices such as helmet
condition and knee caps
- Systemic o Transfusion – cryoprecipitate (concentrate
- Cause – exocrine gland forms of clotting factors)
dysfunction secondary o Prices technique – if there is injury
autosomal recessive trait ▪ Protection
(mother & father – son ▪ Rest (affected extremity)
(dse) & daughter (carrier)) – thick secretions leading ▪ Ice
to obstructions ▪ Compress
o Bronchi – pneumonia then emphysema- ▪ Elevate
complication is respiratory depression - death ▪ Support/splint
o Small intestine – malnutrition leads to dec
ADEK absorption (fat soluble) then N/V Kidney disorders
o Liver – biliary cirrhosis (accumulation of 1. Wilm’s Tumor/Nephroblastoma – tumor
bile in hepatic duct lead to cell death in the growing in renal tissue
liver) - Kidney blastoma –
o Pancreas- pancreatic achylia – metastatic
malabsorption of enzyme (amylase, lipase) - Cause: Unknown
o Male reproductive – dec. semen lead to - Peak incidence – 3-5 yo
infertility - Chief complaint- abdominal distention
- Dx: Quantitative sweat chloride test – sweat is - Mgt- Nephrectomy followed by chemo
collected, Normal - <40 meq/L; 40-60 (borderline) o Pre-op – no prone (avoid rupture &
repeat test on a different site; (+) > 60 meq/L hemorrhage), no tight waist band, no palpation
o Mgt: chest physiotherapy & postural o Post-op – monitor vs hemorrhage, infection and
drainage (WOF- hemoptysis (complication)) I and O(specific)
o Bronchodilators o WOF – temp – because tumor can lead to
o O2 Malignant hypertension
o Flutter mucus device – ask the patient to
inhale (if you inhale a vibrated air leads to 2. Hypospadias (below ventral) & Epispadias
removal of secretions- like a whistle) (above the shaft /dorsal)
o Pancreatin – mix with food (bitter) - Abnormal location of urethra
o Creon – given to remove the blockage NGT - Hypospadias – surgery –
tube; before/after meals Matthew technique
o Diet: Inc CHO, CHON & Fat - Epispadias – Cantwell technique
- Stent use – without anchor to allow urethra to heal
- Mgt post op
o Monitor V/S
o Monitor I & O o Do not help anyone looking for a lost dog/cat and
o If no urine output 1hour post-op – REFER do not accept candies for strangers
o WOF- Cloudy urine – infection o If lost in a store, do not wander around looking for
o No tab bath until stent is removed the parent go at once to a clerk/guard
o No circumcision – needed for future surgery o Children need to learn their full name, address, &
parents name
Musculoskeletal Disorders o Watch for PTSD in any child who experience
1. Developmental Dysplasia of the Hip – common abduction
cause breech presentation NURSING ISSUES
- Assessment – neonate – laxity of
ligament around the hip Part 1: Management of care
o Infant Legal Nursing:
▪ (+) Alli’s sign – shortening of 1. Crime: OFFENSE against society that violates a law
affected limb 2. Tort: is a civil wrong /individual
▪ (+) Ortolani’s test – upon 2 kinds
abduction of the hip – clicking sound femoral head a. Unintentional
moves in the acetabulum ✓ Negligence – you did not do what you’re
▪ (+) Barlow’s sign – upon adduction of the hip supposed to do.
there will be a clicking sound; femoral head goes ✓ Malpractice –you did what you weren’t
out of the acetabulum supposed to do
▪ Unequal gluteal folds
o Older infant and children Person who files the case must show 4
▪ Affected leg is shorter elements:
▪ (+) Trendelenburg’s sign – gluteal folds not 1. A professional owes a duty
balance cause pelvis attempts to maintain balance 2. A professional breached a duty
- Mgt – 3. Harm done
o Birth to 6 months – splinting – hips are abducted 4. The breach of duty was the cause of harm
o 6-18 months – traction – close (mild b. Intentional – an act is substantial to cause an effect
sedation)/open reduction (general anesthesia) – hip ✓ Fraud – results from deliberate deception intended
spica cast for 2-4 months (complication: Cast to produce unlawful gains
syndrome- cause tight application; Sx – ✓ Defamation – false communication or a careless
Abdominal discomfort, abdominal cramps, absent disregard for the truth that causes damage to
bowel sounds) --- flexion-abduction brace for 3 someone’s reputation
months ✓ Libel – written
o Older children: operative reduction and ✓ Slander – verbal
reconstruction ✓ Assault (inflicting mental harm/threat) and battery
(physical harm)– occurs when a person puts another
Child abduction person in FEAR OF A HARMFUL or OFFENSIVE
- Kidnapping by older adult/pre-school- common conduct
Nrsg Interventions: ✓ False Imprisonment – occurs when a client is not
- Instruct the parents to teach a child basic guideline allowed to leave a health care facility when there is
about personal safety that include the following no legal justification to detain the client; occurs
o Do not go anywhere alone when restraining devices are used WITHOUT an
o Always tell an adult where he/she is going and appropriate clinical need. Ex. Pt found in a lock
when he/she will return room
o Say No if he or she feels uncomfortable with the ✓ Invasion of privacy – violation of confidentiality,
situation intruding on private client of family matters and
o Do not talk with strangers or get into their cars
sharing of information with UNAUTHORIZED
PERSONS: Contents:
• Proper covering of physical body 1. Explanation of the Procedure
• Medical records (property of the 2. Explanation of the Diagnosis
hospital/content: property of the client, client 3. Explanation of the Alternatives
can photocopy) 4. Explanation of the Prognosis
• Belongings must be protected and may not be
searched without specific authorization Informed consent is needed if:
• Conversations confidential photographs and 1. Invasive procedures
viewing of procedures require consent 2. Sedation/Utilization of general anesthesia
• Control of visitor access to client and client 3. Blood transfusion
information 4. All procedures to be performed in the OR
REPORT! – someone abuse pt,/ breach
confidentiality Qualified to give Not Qualified
Consent
-18 y.o, alert, conscious, -confused, disoriented
Reporting Laws Exception: oriented -pre-medicated
What To Whom -emancipated minor law -minors who are in the dorm
-married without diploma
a. Assault/Rape -authorities (Police) - pregnant -juvenile detention
b. Animal Bites - animal control center - in the dorm but MUST -minors-foster care
have HS diploma -mentally incapacitated
c. Abuse of elderly - Adult protective services
- military service -mentally ill/retarded
d. Child Abuse - Child protective services - living independently
e. Communicable - CDC & state health dept.
f. Deaths -Coroner Implied consent- ER cases, significant others notified
g. Suicide - Coroner & authorities Informed refusal- pt. suddenly changed their mind even if
h. Dangerous Drugs - Authorities & dangerous drugs they signed it
Board
Patient’s Bill of Rights II. Patient’s Self-determination Act
Privacy - All hospital has a duty to informed pt that upon
Autonomy admission they have the right to advance directive
Treatment Advance directive- legal documents that states the pts
Information wish regarding his healthcare in case he become
Education incapacitated to make decisions, signed by atty and 2
NO to restraints witnesses
To confidentiality Nrsg Considerations:
Services (community) 1. Nurse- gives info that he/she has the right to sel-
directive
La leche league- breast feeding mothers 2. Verify legality – originally within the day
3. Members of healthcare team are NOT eligible to sign
AUTONOMY
I. Informed Consent Components of an advance directive-
Components: Special Medical Power of atty AKA: Durable power of
Patient Doctor Nurse atty – Only for healthcare decisions; the pt appoint
-signed -explains and -witness
18 yo, alert, read the content, -check for the
healthcare proxy who will decide on his/her behalf; any
conscious, complications, presence of person decide DNR/DNI
oriented, - legally gets the signed Living will- if present NO SMPA needed; signed by atty
Pt can’t read or signature informed
write- Thumb -sign consent and 2 witnesses; lawyer, attending Dr, significant others
mark, check or who verifies the pt is legally allowed/capable to signed;
X
enforced when the pt is emancipated; NO below 18 yo;
NO healthcare professional specially involved in direct 1. Autocratic/Authoritarian Style – centralized
care, beneficiaries of his will/estate type of mngt; Disaster/systematic discharge duty;
Verbal request – ONLY funeral arrangement allowed only one decide (top)
2. Laissez-Faire/Freestyle – let the subordinates
Recognize what is the scenario decide
Ask what the question is asking 3. Democratic/Participatory- leader encourage
Comprehend feedback & base on input leader decide
Eliminate- 3X
Vertical approach:
Ethical principle Nrsg Mgt.
Organ Donation 1. Director of nursing
Internal organs - kidneys, heart, liver, pancreas, 2. Nurse Supervisor
intestines/lungs/skin/bone & bone marrow/cornea 3. Case Manager/Charge nurse
Law- uniform anatomical act 4. Licensed Practical Nurse/LVN/PN
Age of eligibility – 18 y.o. and up 5. Certified Nurse Act /UAP
Heart - 40 yo limit
Liver & pancreas- 50 yo limit Assess 1st – suspected, seems
Kidneys- 65 yo limit Incident Report – is a risk mngt tool for quality
Who can decide Organ Donation if pt expire: improvement
1. Spouse
2. Adult children When to file an incident Report
3. Parents 1. Injury to the pt/visitor
4. Siblings- Adult 2. Medication error
5. Guardian 3. Any variance: (+) (-) that warrants documents
HTLV III- test for presence of HIV
Contraindication to Organ Donation Steps in reporting and completing an incident report:
1. CD/HIV/AIDS & STD 1. Attend to client’s needs 1st(assess) – do not leave
2. Hepatitis (all types) the pt
3. Malignancy dse organ 2. Notify the supervisor
3. Dr. will give order
Drugs that prevent Organ Rejection (4cs) 4. Carry out Dr’s order
1. Cyclosporine (Sandimmune) 5. Evaluate pt. response
2. Cellcept 6. Write if clients is stable – v/s check
3. Corticosteroids Never document that you write an incident report
4. Cytoxan Other variance/occurrence that warrants
Echinacea- CI: immune system stimulant/drug interaction documentation:
EMS- 911- house- no EMS code, no CPR 1. Intoxicated colleague – 1st notify the supervisor
DNR-hospital-initiated & signed by MD; inform the crash 2. Supervisor will assign a team to confront the nurse
team NOT to continue and conduct an investigation
When to STOP CPR 3. Supervisor will assign a buddy nurse if suspected
1. Spontaneous breathing Delegation
2. Qualified personnel on the team 5Rs
3. Pt pronounces dead Right task/responsibility
4. Personnel are exhausted Right Circumstance
Nrsg Mgt: Right Person
Different Styles of Nrsg Mgt: Right Communication – verbal & written which is
specific- so you are not liable if mistakes done
Right Feedback
Principles of delegation
1. A nurse can only delegate those tasks for which *if other options cannot provide remedy- REPORT!
that nurse is responsible
2. The delegator remains accountable for the task Horizontal Approach
3. Along with responsibility for a task, the nurse who Nrsg Mngt: Dr is the leader
delegates must also transfer the authority Rn= Dietician = Therapist = nurse clinician = social
necessary to complete the task worker = home health nurse
4. The delegator knows well the task to be delegated
5. Delegation is a contractual agreement that is When do we notify the provider/physician:
entered into voluntarily – assertiveness 1. Medical emergency – Inc ICP, shock, airway problem
6. Consider the scope of practice of the nursing 2. Surgical emergency – abruptio placenta
personnel 3. Alteration in client’s v/s
4. Neurovascular compromise (8 Ps)- Circulation,
Delegate – authority & responsibility but NEVER the Mobility, Sensation
accountability; need to check needs, check skills and area - Pain inc
where they come from - Paresthesia- most important
- Pallor
Steps to Delegation - Pulselessness
1. Define the task - Paralysis
2. Determine the delegate/who will receive it (is the - Polar-cold to touch
task within the scope of practice) - Poor capillary refill
3. Communicate clearly about expectations regarding 5. Toxicity level of the drug- check allergy
the task (state clearly the outcomes you expect) 6. Alterations in the drug dosage/route/discontinue
4. Reach mutual agreement about the task to be - Not if pt refuse – notify DR as well as cases
completed (understand) when sudden change happens
5. Monitor the task and provide guidance as needed
6. Evaluate results (results obtained) PRIORITIZATION
7. Provide feedback to individual on outcomes Nrsg Considerations
performance right/wrong 1. Client then equipment
Registered Nurse (RN) 2. Nursing process
- Delegator, decision maker 3. Maslow’s hierarchy of needs
- Assess, NCP, Initial-admission, Health 4. Safety principles: child and elderly abuse-Prio
teaching/discharge teaching, transcribing dr orders, 5. Understand terminologies
client rounds with dr, client for transfer-for 6. Question and answer agreement
endorsement, invasive procedure sterile procedure-
BT, IV, insert cath, tracheostomy, suction, OR, Airway Breathing Circulation
unstable – newly admitted, post-op, complication Block – dentures, Any change in rate Anything related to
tongue, secretions respi heart and blood
- Wound care-complex/complication-RN, drugs- A/E, Bronchospasm Kussmaul’s vessels
O2 regulation- routine, chemo, internal implants Insect bites, pruritus, breathing,DKA Shock, MI
antibiotics, Cheyne’s stokes- Inc Severe vomiting and
LPN/LVN/PN – tech doers, wound care- anaphylaxis ICP – lead to ataxic diarrhea, DHN, lead
simple/uncomplicated, meds oral, IM, SubQ, except Facial burns, singed breathing- apnea to electrolyte
intravenous, cast/traction without complications, Data Hot air- cause Cluster breathing imbalance – dec BP
laryngeal edema Neuromuscular
collection, intravesical chemotherapy *Tracheal deviation compromise 8Ps
UAP/CAN –routine of care, feeding but with dysphagia-
RN, they can put the cannula, ADL’s, ambulation, Transcultural Nrsg
bathing, feeding, skin care, oral care/suctioning, Culture- norms and practices of a particular group
grooming, v/s, cleansing enema, occult blood test, I & O, Culturally Diverse Nurse – refers to variability of nursing
urinary dip stick, accuchecks, remind pt approach
Ethnocentrism – perception that one’s own ways is best - 40 days belief – do not take a bath post delivery
when viewing the world (The American way is the best) – - Eye avoidance
culture wants to be superior - Do not touch head – Holy/sacred
Race- members of the same group share distinguishing - Smiles/nods: without understanding -risk for injury
physical features - Dominant: males/sons- eldest son
Discrimination – latin discriminare- distinguish between, - Disease- TB – migrants dse
biased, showing partially, unfair treatment of people - Traditional medicine
(race/gender/religion) - Flexible time schedule
Steriotyping – standardized conception of a person or - Professional interpreter
group - Bluish mark round with measurement – cupping
- All nurses provide tender love and care - Donquai – dysmenorrhea
- All drs are intelligent - Ma huang- weight reducing pill, CNS stimulant, loss
- Vietnamese are the valedictorians (good in war) of appetite, like Ritalin- Inc. dopamine
- Professional interpreter
- Male dominant American- on time, 5-10 min before the time
- Coining and cupping- ventosa; circular bruises in White Americans- eye contact & Europeans, future time,
same sites Germ theory- most compliant, autopsy
- Mother is rubbing a coin at the back of the child - 10 leading causes of death
Culture Shock – state of distresses when a person is - CAD; MI
expose to a strange environment - Cancer
Acculturation – Process of adopting the cultural traits of - Respiratory dse
another group - Accidents
NANDA – Ineffective verbal communication - DM
Social Isolation - Influenza
Risk for non-compliance - Pneumonia
Risk for Injury - Alzheimer’s
Native American – pattern, they will not arrive - Kidney Dse
- No eye contact - Septicemia
- They do not believe in germ theory African American
- Harmony with nature- Pochahantas - Privacy/Confidentiality
- Sacred meal: blue corn meal- inc in simple sugar - Do not ask about relationship
- They do not take meds - Sickness: Demons & evil spirits
- Medicine man- healers/albolaryo - Significant Person: religious leader: church, mother
- DM type 1/juvenile DM - Soul food; fried foods
- Renal failure - Time: flexible
- Alcoholism - Close family ties
- Lowest survival for cancer - High fat and cholesterol Love fatty foods
- Speak with a low tone of voice - Hypertension, stroke
- Touch hand for greetings- how - Cancer (all types except skin cancer)
- Indian time: do not arrive on a specified time - DM type 2, Glaucoma
- Skin assessment: pallor-buccal mucusa/palate;
Asian/Chinese American – 1-2 hours late before the Petechiae – palm, soles of the feet; Jaundice- sclera,
meeting nail beds
- Fruits and veg - Female- most significant – Mother
- Yin-cold (white and dark
green); Yang- hot Mexican American – sickness; punishment fr God
(red,orange,yellow) - Magical thinking
- Reluctant to donate blood
- Usog: “Evil eye”/ Mal de ojo – just touch the baby
post admiration Judaism – torah – holy book
- Amulet- Señor milagrosa - 5 books of moses
- Curandero/Curandera- healer - Stress
- Post-partum practices- wipe oil cream - Ulcerative colitis, chrons dse
- Cancer: gallbladder - Cooleys anemia/thalassemia – immunocompromise,
- Catholic: parish priest, chaplain wbc immature
- Protestant: preacher/pastor/minister - Rabbi-priest
- Spanish interpreter - *Kosier diet-lawful diet & allowed; should be
- Wide frame attitudes: time slaughtered; no beef & dairy products at the same
- Father: decision maker time, well done, no pork, leviticus food (shrimps,
- Children-most important person cramps, shells, fish without fins and scales), like SDA
- Soul food: torrillas & chili - When a Jew dies there should always be a family
- High fat diet – gall bladder/cholecystitis member present
Japanese Americans – 30 mins before the meeting Roman Catholic – Belief- no abortion, natural method of
- Technology: life is fast family planning, holy trinity
- Great value of time - Organ donation: yes
- Father: decision maker - Abortion: no
- Leukemia - Death & dying: call members of the family
- Cancer: skin, breast, brain - Sacraments
- Cancer: stomach (smoked/cured foods) a. Penance
- Foods that causes cancer: grilled, processed, pickled, b. Holy communion
dried ramen, dried fish, fermented foods, alcohol c. Anointing of the sick
- Dokuturu-dr - No meat on good Friday & Ash Wednesday
Hinduism- belief-reincarnation Mailine Protestant – No tobacco and alcohol

- Organ donation: yes Islam- food: no pork, no Elixir, no alcohol, no porcine
- Post mortem care: body wrapped in white or orange insulin- comes from pigs, capsule case-pork intestine
cloth then cremated - Halal- lawful
- Practice: yoga/meditation - Ramadan- June and July, exempted: young old and
- Food: vegan/strictly vegetarian sick
- Ashes: thrown to the holy river- ganges river - Doctors/nurses- female for female patients give meds
- Placing oil in the pt forehead on right hand minimizing touch therapy
- Death and dying – doctor declares death; never touch
Buddhism – belief-enlightenment the dead body; body washed by relative of same sex,
- Practice: meditation wrapped in white; body positioned facing meca (east)
- Food: vegan - Burial within 24 hours
- Post mortem care: allow the body to be untouched for - Koran- (Q’ran)
3 days - Evil eye
- Organ donation: yes - Male dominant
- Death and dying (+) feeling - Tie/ place cotton to any opening
- Allow burial & cremation
- After death: first touch the top of the head and say Jehovas witness – food: no blood of animals
“go to the pure land, or precious human birth, heaven - Blood transfusion: only plasma expanders to maintain
or safe place” body fluid in the body
- Can donate organ but with no blood coming from the
other person
- Only plasma expanders toxic subs, and helps eliminate the toxins in
the body
Mormons- food restrictions: no tea, no caffeine, no
alcohol, no chocolates, no cola, no tobacco, no stimulants Paracetamol – should be child proof
- Women clothing: wear special sacred undergarments container; hepatotoxic- WOF: upper right
at all times quadrant pain, Antidote: Acetylcysteine
(Mucomist)
Seventh day Adventist – Food: Leviticus food (avoided)
- Fish without fins and scales Narcotics – CNS depressant; WOF: altered
- No squid, no shrimp LOC until child sleeps quietly, monitor RR
- No pork, no crab Antidote: Narcan
- Holy day of obligation: Sabbath day- starts 5 pm
Friday to Saturday- 5 pm Corrosive Substance- only give H2O -safe,it
- Holy day of obligation: sabbath day-starts 5 pm will dilute; Locked cabinet, High shelves,
Friday to Saturday 5 pm- sundown WOF: severe pain cause it will eat up mucosa
Call the local poison control center
Safety: Accident Prevention
1. Infancy- no small parts, in the crib- no floppy toys Lead: AKA plumbism- houses built in
- Snacks – no grapes, peanuts and hotdogs same 1960’s -paint is lead based, Toys, soil,
as toddlers newspaper, H2O with lead pipes before you
- They roll but cannot go back so NO prone, get H2O allow it to flow for 2 mins before
SIDS (3-6 months) getting water, home based industry (pottery,
- Peak SIDS/CRIB death during fall and winter stained glass window) WOF: lead goes to the
- Crawling – 6-8 months so never leave in a blood, destroy RBC; bones-iron deficiency
couple bed anemia, loss of consciousness, activity
- Immunizations intolerance, greenstick fracture, pathologic
- Crib slots- 2.375” distance fracture (Ca absorption problem); plan rest
- Car safety: infant to 1 year or 20 lbs. infant periods; diet- blue berry, raisins, prunes, dark
seat, rear facing, center at the back colored food – inc iron
2. Toddlers – prone to injury/ accidents/MVA, abuse 3. Pre-school (3-6) and school-age (6-12)
- teach the parent to address the negativistic - Prone to head injury and greenstick fracture
attitude with understanding & humor - Wear helmets, elbows and knee pads
- Accidents: - The rider of the bicycle should stay on the
-MVA flow of traffic parallel to the cars
-Falls- stairs (gate) - Emergency accident ingestion – check child’s
-Drowning age and weight, drug calculations
-Burns- common cause scalding - >40 lbs- pre-school – OK left/right, they need
-child abuse/sexual abuse – STD at young age a boaster seat
-Car safety- front facing center, 20-40 lbs, - School age- until 12 above 6o lbs – shoulder
center back seat harness
-oral ingestion of poison- common:
aspirin-anti platelet – WOF -unusual 4. Adolescent/early adulthood
bleeding, ototoxic-tinnitus, not a corrosive - MVA
drug so OK syrup ipecac- intention inducing - Suicide
vomiting within 10 mins otherwise leads to - STD: chlamydia and gonorrhea –
cardiac arrest, not at all time esp. kids- mucopurulent discharge
antidote Vit K, activated charcoal-binds with
- Infectious mononucleosis- avoid contact c. Adequate lighting – red light lamps no flash
sports, bicycling, inc risk of splenic rupture – light
no kissing, sharing utensils during treatment, d. Toilet seats: raised
kissing’s dse, espstein barr virus e. Grab bars/handrails in hallways &
- Suicide- late adulthood; evening, Monday bathrooms
(manic) holidays and anniversaries times of f. Dress/shoes – warm clothing
renewed pain g. Music- relaxing music
- If one of the twin commit suicide WOF the h. Assistive devices- canes and walkers
other twin i. Remove-dials of oven
j. Shower-hot shower- test
5. Middle adulthood changes in aging k. Bowel & bladder retraining – acid-ash diet-
Physiologic changes cranberry juice
Cognitive decline: Alzheimer’s dse, dementia
Safety-long term care facility-name and picture *Risk for osteoporosis:
-hospital ward – room nearest to the Older people
station Sedentary lifestyle
Visual acuity: Presbyopia (farsightedness) Trauma
- Notify the Dr to prescribe reading glasses/ Excessive smoking
convex lenses Over a cup of coffee
Hearing – Presbycusis
✓ Do not shout/ pitched tone; normal tone Gingko biloba- blood thinner; inc blood circulation, no
and stand in front of the patient aspirin
Lung residual volume- weakness of Garlic- blood thinner, no aspirin
diaphragm – Risk for pulmonary disorders ; flu; Disaster Planning
pneumonia and influenza (flu) – H.T. annnual Steps:
flu shot and pneumoccocal vaccine every 5 yrs 1. Know the agency disaster plan
Clotting – aspirin , MI/ CAD/ CVA 2. Activate the agency disaster plan
Impaired tactile stimulation: hypothermia and 3. Activate the personnel
burns 4. Activate the central supply
Color difficult to be distinguised: Purple 5. Prioritize the pts
✓ Easiest - RED
Bone demineralization – osteoporosis Rescue/discharge/evacuation – no assessment
estrogen Ca+ rich diet; Ambulatory clients then bed ridden then critically ill- fixed
Ca Supplement Fosamax or inc dilated pupil-last
weight bearing exercise
ED/ER/TRIAGE/Disaster
Gastric enzymes : indigestion constipation *assess 1st
OFI/ fiber ; do not abuse laxative lead -Emergent – no delay
to constipation -Urgent- delay 1 hour
Bladder capacity : shrink Incontinence -non-urgent- immediately in a day delay
Kegel’s exercise Critically ill-last
GFR: drug toxicity
No taste buds – dulled tatse tendency Bioterrorism – is a terrorism by intentional release or
Salt hypertention dissemination of biological agents such as bacteria, viruses
Elder safety or toxins
a. Provide safety environment- NO 2nd Floor - These are used to cause illness or death in people,
b. Restraints- wrist/least animals or plants
- Biological agents can be spread through air, water Protection: N-95 mask,
Hepa filter
and food mask/particulate mask
Droplet -particles: size 5 microns Diphtheria
Category A: high-risk to public or national security, easily -room: private Rubella
Cohort: Yes, two droplet Oral pharyngitis
spread, result death rate – ex. Anthrax (cutaneous) DOC: pt, 3ft separation Pertussis/pneumonia
doxycycline- early detection 24 hours, if more sepsis Distance: 36 inches Erythema
Protection: surgical effectiosum-5th dse-
Category B: moderate illness, low death rate (E. coli) mask characterize by
Category C: easily available, produce & spread prodromal stage flu-
like, Sx which is
contagious then slap
Infection Control: cheek appearance next
Prevention of infection sx or rash in the body
lacey appearance check
Medical Asepsis- routine medical procedure and do rashes not contagious
handwashing, gloves and gown Tonsilitis
Surgical Asepsis- Sterile tech; all OR procedure, Influenza
Scarlet fever
scrubbing & sterile gloves and gowns Mump/meningitis
Contact Particles: secretions MRSA (present in the
from eyes, ears, skins, skin, if with break
Prevention of spread of Infection wounds, genitals DOC methicillin 1st
1st tier standard precaution: Private room then vancomycin if not
1. To all pts at all times Cohort improve) and VRSA
Distance: 3 ft /36 inches (DOC: IV/IM-
2. Handwashing: before and after pts contact Protection: pt must have imipenem or
3. PPE own set of equipment meropenem- cilastin-
All protective equip prolong effect)-
a. Gloves- when handling bodily common nosocomial
fluids/secretions and infection materials infection; staph aureus
b. Gown- soiling is likely to happen VRE- enterococcus
Clostridium difficile
c. Goggles, facemask, face shield – diarrhea
splashing is likely to happen; irrigating, Hepa B,C,D,G
Conjunctivitis
suctioning RSV-bronchiolitis
Impetigo-non-
*greenish- trichomoniasis occlusive dressing adm
“cycline” “mycin”
Cottage cheese- candidiasis mittens No touch
Grayish fishing – Gardnerella vaginosis, poor Enteric Fecal route Hepa A, E
Private room- washing Shigella
hygiene station/bathroom facility Salmonella
Syphilis/HSV II- Painless chancre Cohort Norwalk virus
Needle sticks, pierce& cuts: what to do: Protection- gown and Cryptosporidium –
gloves like amoeba, common
Wash hands and prolong
Report to sup hospitalization
Giardiasis – diarrhea
Assess the cut/prick then pt common day care
Prophylaxis – depend on pt condition children
*Legionnaire’s dse- dirty aircon Protective or Precaution Cancer
Neutropenic Protection: mask Chemo
Transmission-Based/Secondary precaution Reverse AVOID: AIDS
Precaution Nrsg. Diseases isolation Crowds HIV
Considerations Potted plants Organ transplant
Fresh flowers Immunocompromise
Airborne -Particles-size 5 microns PTB, PTB suspect
Fresh fruits/veg Major Burst/surgery
(AB) -Room: private (keep common HIV pt when
Improperly cooked meat – more than 50 % of
door close) (-) air unknown source
Handling pets the body
pressure Herpes zoster
Stagnant H2O Dec WBC/RBC
Air goes outside Varicella zoster
Live attenuated vaccine
atmosphere 6-12 SARS
Raw foods
exchanges/hr Measles
Gardening danger of
Cohort: strictly same
toxoplasmosis
causative agent
Handling birds nurses with predetermined standards and criteria
dropping-
histoplasmosis – severe
while the nurse is providing care during stay
respi. Distress syndrome - The process is SIMILAR TO THE NURSING
cause by fungi PROCESS AND INVOLVES A
MULTIDISCIPLINARY APPROACH/ team
NCLEX UPDATE - When quality improvement is part of philosophy
Federal/ state laws & legal Organization of a health care agency, EVERY STAFF
Act- federal law MEMBER becomes involved in ways to improve
1. Tarasoft Act – mandatory reporting of client care and outcomes
suicidal/homicidal pts; duty to inform the 3rd party
2. Good Samaritan laws – encourage to assist at SBAR or Situation Background Assessment and
accidents and emergencies; it cannot protect Recommendation
proven intentionally hurt pt or you did a gross - Reduces the incidence of missed communication
negligence - An effective mechanism to level the traditional
3. Nurse practice Act- differs per state hierarchy between drs and other caregivers by
4. State Board of RN – safe practice nursing building a common language platform for
5. M’Naghten Rule – insanity plea by defendant communicating critical events, thereby reducing
6. Handicapped Children Act – provides schooling barriers to communication between healthcare
in the least restrictive environment professionals
7. JCAHO (Joint Commission on Accreditation of - Helps to prevent breakdowns in verbal and written
Health Organizations) – non- gov’t organizations communications, by creating a shared mental model
comprise of medical associates, AMA, ANA - As a memory prompt, it easy to remember and
accreditations encourages prior preparation for communication
8. HIPPA or Health Insurance Portability and - Used during handover, can reduce the time spent on
Accountability Act of 1996 – protects privacy & this activity thereby releasing time for clinical care
confidentiality of cts health information; minimize
the chart & tell the dr to log- out
St. John’s Wort – anti-depressant -mimics action of
9. Consolidated Omnibus Budget Reconciliation SSRI (effectivity after 4 weeks)
Act- health benefits that protect health insurance - CI: SSRI/MAOI/TCA/OTC ampethamines,
coverage when employment is terminated stimulants; OTC – decongestants, anti-coagulants,
10. EMTALA- Emergency Medical Treatment & anti-depressants
Active Labor Act – all hospital oblige/duty to - Nrsg Mgt: avoid sun exposure
attend to emergency treatment
Echinacea- outbreak viral infection
- Immune system stimulant
- Taken up to 6-8 wks only
Quality Improvement - More than 8 wks autoimmune dse
- Objective criteria – used to monitor outcomes of - CI: sandimmune-organ transplant
care and to determine the need for change to
improve the quality care Gingko biloba – enhances memory
- Focuses on process or systems that significantly - Blood thinner
contribute to client safety and effective client care - Treatment for dementia/alzheimers
outcomes - S/E prolonged bleeding > 9 mins
- A RETROSPECTIVE “looking back” audit is an - CI: pt taking anticoagulants/garlic
evaluation method used to inspect the medical
record after the client’s discharge for Evening primrose/Blue Cohosh – for PMS
documentation of compliance with the standards Milk Thistle- help regenerate liver cells
- A CONCURRENT “at the same time” audit is an Licorice – root product releases high Vit C
evaluation method used to inspect compliance of
Black Cohosh – for menopausal
Cranberry – for UTI Carcinogenesis – conversion of a normal to abnormal
cell
PRIORITIZATION 1. Initiation – 1st exposure to carcinogens; reversible
What: nurse DO 1st- Nursing process 2. Promotion – repeated exposure; DNA
Assess “seem” “suspected” mutation/alteration
Ask Normal – Protooncogenes – capacity to control cell
Check growth; mutation --- abnormal oncogene – cancer cell
Determine proliferation
Examine/Evaluate Turn off – “tumor gene suppressor” “DNA repair
Find gene”
Gather History 3. Progression – metastasis thru blood or lymphatic
Identify system
Judge
If without suspected/seem and with data sp
move to Intervention
Who: should the Nurse SEE 1st – ABC
- Client centered
- Find hypoxia (irritability, restless, confusion)
Airway, breathing – if respi problem, inc. ICP
anaphylaxis
Angiogenesis (artery)– cancer creates its own blood
Immunocompromised
supply
Real bleeding
Safety
Cancer – uncontrolled cell growth
Try infection (complication)
- Characteristics - Poor differentiation
Heat= temp= 100.4°F or 38°C – nrsg
o Altered biochemical properties
independently
o Chromosomal instability
Age- too young or too old
o Capacity to metastasize
Question Problem
- Grading – cellular aspect of diagnosis
1. Physiologic
o Grade 1: well differentiated (mild dysplasia)
a. Complications – the pt complaining, states,
o Grade II: moderately differentiated (moderate
experiencing A/E or S/E; acute or chronic\
dysplasia)
b. S/Sx
o Grade III: poorly differentiated (severe
2. Psychologic
dysplasia)
Risk for injury
o Grade IV: undifferentiated
2 types
- Staging – tumor growth/clinical aspect of Dx
a. Directed unto self- suicide
o Stage O: carcinoma in situ – in place
b. Directed unto others- manic, schizoparanoid
o Stage I: tumor limited to the tissue of origin
o Stage II: limited local spread
ONCOLOGY/INTEGUMENTARY o Stage III: Extensive local and regional spread
Oncology (distant tissue)
The cell cycle – 23 chromosomes o Stage IV: metastasis (other organ) end stage
1. Interphase (G1) - Cell accumulates nutrients &
protein; RNA synthesis Physiologic responses to Oncologic and Hematologic
2. Synthesis (S) – DNA synthesis & replication happen disorders
3. Gap (G2) – resting phase; gap between synthesis & General responses
mitosis - Pain (putting pressure on other organ/tissue)
4. Mitosis (M) – cell division
- Cachexia (muscle wasting, cancer cell is always
hungry) 4. Testicular Self-Exam – monthly
- Bone marrow involvement o after warm shower in front of the mirror –
- Anemia observe for swelling, palpate soft cord like
- Thrombocytopenia structure
- Leukopenia o Normally spermatic cord
- Infection – reverse isolation needed o Abnormal – hard rubber like lump –
- Neurologic S/Sx- attack brain 1st testicular cancer – REPORT
- Respiratory distress
- GI & GU Sx 5. Digital rectal examination – done to detect prostate
cancer
Seven warning signs of cancer o Knee chest position
C – hange bladder & bowel habits o Yearly starting 50 yo
A – sore that does not heal o Abnormal – hard prostate (cancer), BPH –
U – nusual bleeding/discharge soft, enlargement
T – hickening/lump
I – ndigestion/impaired swallowing 6. Sigmoidoscopy/colonoscopy – starting 50 y.o.,
O – bvious change in moles/warts visualization of the sigmoid every 3 yrs/ visualization
N – aging cough/hoarseness of voice >2 weeks of the colon every 5 yrs
Pre – secure consent
Benign Malignant NPO 6-8 yrs
Infiltration None Yes Enema 1 hour prior
Capsule Yes None Mild sedative
Cell Well Poor Position – Left knee chest/lateral sim’s
characteristic differentiated
During procedure: monitor vagal stimulation,
Metastasis None Yes
monitor HR & RR anything dec REPORT!
Spread of Slow/none at all Rapid
growth Post: assess perforation, fever, bleeding,
abdominal pain
Early detection and screening
1. Breast self-examination – monthly; always begin at 7. CT Scan – high form of x-ray, with or without
upper outer quadrant (axillary part) contrast; with contrast (IV/oral)– seek consent,
o 2-3 days post menses if regular NPO 6-8 hours, assess Crea – to check if normal
o irregular – immediately post menses Post: Inc OFI
o menopause – same day each month
8. MRI – high form of CT scan, if claustrophobic-
2. Mammography – x-ray of the breast sedate
- Prep – no application of powder, lotion, cream, deo CI: metal implants
cause it will coat the cancer cell
- yearly starting 40, equivalent to 1hour exposure to 9. Bone Marrow Exam – Site: infant – long bones –
the sun femur/tibia; Adult: posterior iliac crest, used local
anesthesia
3. Pap smear – high risk – sexually active, multiple Post: monitor infection & bleeding, apply direct
sexual partner pressure at least 30 min or high risk for thrombo.
o yearly starting 21 yo
o not at high risk – 21 yo every 3 years 10. Oncofetal Antigen – normal if present in fetus if
o 30-65 yo every 5 yrs persisted in adult it is Cancer
o Prep – NO vaginal meds, sex, douching 2 Ex. AFP (alpha feto protein)
days prior CEA (Carcino embryonic antigen) – colon Ca
PSA (Prostatic Specific Antigen) – prostate Ca • Vinca alkaloids: Vinblastine (Velban)/
VinCrinstine (Oncovin) – S.E. neuropathy/
Treatment Modalities neurotoxic/ numbness/ paresthesia (WOF:
1. Surgery initial sign)/ Constipation/ phlebitis at IV site
Types:
a. Diagnostic – biopsy (aspiration, incisional d. Hormones
(sample tissue incises), excisional (entire cyst • Tamoxifen (Nolvadex) – for breast & ovarian
removes)) Ca – S.E. Inc. Risk of uterine Ca; S.E.
b. Prophylactic – goal is to dec risk edema/hypercalcemia/inc risk of uterine Ca
c. Curative – to remove the tumor • Diethystilbestrol (DES) (Stilphostrol): If taken
d. Control – prevent spread by pregnancy (male-testicular Ca, Female –
e. Palliative – relieve Sx cervical Ca)/ S.E. edema/ hyperurcemia/
f. Reconstructive/Rehabilitative – repair/aesthetic impotence/gynecomastia in males
purpose • Testosterone (Depotestosterone): same with
DES
2. Chemotherapy – hepatotoxic, nephrotoxic, cytotoxic • Megestrol (Megace)
– actively dividing the cell: 1st bone marrow • Pridnesone (Deltasone): S.E. edema, impotence
(pancytopenia), 2nd hair follicle (alopecia) 3rd mouth
(stoma, mucocytic)) e. Antitumor Antibiotic – Inhibits CHON synthesis in
a. Alkylating agent – cell-cycle nonspecific; toxic to general; cell-cycle nonspecific
hematologic cells; Inc risk for bleeding; miscoding
• Doxorubicin (Adriamycin)/ Daunarubicin
DNA (Daunomycin) – S.E. irreversible
▪ Cyclophosphamide (Cytoxan) – bladder
cardiomyopathy, cardiotoxic so ECG at bedside
toxic cause hemorrhagic cystitis – painless
• Dactinomycin (Actinomycin D) – extensively
hematuria so inc OFI
used for pediatric sarcomas
▪ Cisplatin (Platinol) – nephrotoxic, S.E.
• Bleomycin: S.E. pulmonary fibrosis – pulmo
alopecia/gonadal suppression/nephrotoxicity
toxic
▪ Busulfan (Myleran) – pulmotoxic, S.E.
pulmonary fibrosis & wheezing
Preparation:
b. Antimetabolites – cell-cycle specific; toxic to
Wear – nurse should wear mask, gloves, long
hematologic cells – Inc bleeding; Action – interferes
sleeves, gowns
with needed enzyme for synthesis (S phase)
Do not – expose to sunlight; refrigerate
▪ Methotrexate (Rheumatrex) – avoid folic
Use needles & syringes – biohazard (orange)
acid; S.E.: alopecia/ stomatitis/ hyperuricemia/
Yellow is for infectious
hepatotoxicity; Antidote: Folinic acid
(“Leucovorin rescue”) – lower form of uric
3. Bone Marrow transplant
acid
• Donors: autologous – self
▪ Cytarabine (Ara-C) – WOF: muco/stomatitis
Allogenesis – family member
– initial sign of toxicity; S.E. Conjunctivitis
Syngeneic – twin
with high doses
Stages:
▪ Mercaptopurine (6-MP) – S.E.
a. Harvest – adult 500-1000 mL – aspiration site
hyperuricemia/hepatotoxic
is same
▪ 5 FU (fluoro-uracil) – S.E.
b. Conditioning – (pt) by another round of
alopecia/stomatitis/diarrhea/photosensitivity;
radiation and chemo
oral thrush – Nystatin – white patches- CALL
c. Transplant – IV @ bedside
DR! // do oral care
d. Engraftment – last 3-5 weeks; pt accepts the
c. Plant alkaloids – cell-cycle specific; inhibit mitosis
donated bone marrow; critical to pt cause pt is
(M phase)
immunocompromised
Complications: Principles: S – Shield -lead apron
a. Acute rejection (AKA failure to engraft) – pt T – time – up to 30 mins/shift & visiting hours
creates antibodies D – Distance @ least 6 ft, same using
b. Graft vs Host Disease – the donor that docimeter
produces antibody (bone marrow transfused) In cases of dislodgement
c. Liver Failure – hepatotoxic conditioning & the Long handled forceps
donated bone marrow occludes the blood Lead Apron
vessel of the liver Lead-like container lined
4. Radiation Therapy
Reduces bone marrow activity (Pancytopenia) Oncologic Disorders
Anorexia Brain Cancer
Dry mouth Risk Factors:
Irritation of mucusa – muco/stomatitis Boys common
Alopecia Radiation
Toxic effects/teratogenic AIDS
Impaired skin integrity (burn) – red dry scaly Inherited
Over fatigue Neoplasm from other organs
N/V S/Sx:
1. Cerebral hypoxia – dec LOC
External Internal 2. Inc ICP
Focus: Skin care Unsealed Sealed 3. Poor school performance
Do’s: Adm- IV/oral Adm- beads/pellets-
Keep skin dry intracavitary cesium
4. Frontal – (PAST) personality changes,
Clean with mild (cervix) Attention span, Speech slurred, Thinking
soap Radioactive – pt & Radioactive: pt (as
Report! Moist
difficulty
excreta long as beads are
weeping 48-72 hours inside) 5. Temporal – Short term memory; loose
desquamation of Excreta is not hearing
skin- 2nd ° Health Teaching:
Wear loose clothing 6. Parietal – senses issues
Instruct pt to flush Prio: Prevent
Sunscreen toilet twice dislodgement 7. Occipital – vision
Don’ts
Remove the ink
Clean toilet with Advice pt CBR 8. Cerebellar – balance & coordination
bleach without bathroom
mark Wash soiled lines privileges Brain tumor - DI – monitor Urine Specific Gravity
Lotion or powder separately Enema prior to Nursing Dx: Risk for Injury
Exposure sunlight Do not share insertion
Extreme temp bathroom with Low fiber diet
Mgt.:
Tight clothes children & preg. Supine or up to 30° 1. Surgery – supratentorial – semi-fowlers
HOB Infratentorial – supine/flat
Male: sit during
urination (avoid 2. Radiation
splashes) 3. Chemotherapy
Nursing Care –
Room precaution – Private Laryngeal Cancer – voice box
Activity – CBR without bathroom privileges Mets: Lungs
Urine & Bowel – Proper disposal Risk Factors:
Diet – low fiber Father/male/African american
Head of bed: supine/30° HOB Forthy & Inc. with age
Family history
Summary of Radioactivity Frequent straining voice
Radiation Radioactivity Frequent smoking
Therapy Patient Excretions Dx.
External X X
Internal (Sealed) ✓ X Laryngoscopic Exam
Internal (Unsealed) ✓ ✓ Biopsy
Assessment: Thyroid Cancer
Hoarseness of voice – initial >2 weeks Risk Factors: Female
Foul Odor breath Forty-five & above
Weight loss Family History
Dyspnea/Dysphagia – Late Assessment:
Painless palpable neck mass Painless palpable node
Mgt.: 2 types Laryngectomy Pain in breathing
1. Partial – with voice after surgery Pain in swallowing
o Neck breather Mgt:
o Semi-fowlers 1. Surgery: total thyroidectomy
o Concern – Communication – paper and pen/ CI: hypocalcemia – WOF – tetany,
whiteboard/ call button laryngospasm
2. Total – without voice Hemorrhage – highly vascularize,
• Prio – open, keep stoma moist – apply check the nape for assessment
petroleum jelly, apply stoma bib, you may use Edema – low/semi-fowlers/ rest voice
humidifier, avoid aircon Laryngeal nerve damage – ask client
• Speech therapy – post surgery to speak for assessment, hoarseness – normal 6-
a. Esophageal speech 12 hours, if > 12 hours – laryngeal damage;
- 1wk post procedure with Dr’s order place trache set at bedside
- 1 hr post meal, instruct burp/belch 2. Radiation: Systemic- RAI-SI/121
- Disadvantage- hyper nasal sound CI: pregnancy, lactation, children
b. Electrolarynx: AKA: Kancer Karoo/ 3. Thyroid replacement – lifetime
voicebach device
- Commonly use Esophageal Cancer
- Disadvantage – robotic voice Risk Factors:
c. TEP – Transesophageal Puncture Esophageal Stricture
- Dr create fistula between esophagus & Smoking
trachea Older than 50 yo
- Advice create normal voice Population of African-American/poor oral hygiene
- Strict aspiration precaution Hereditary
Alcohol
Lung Cancer – spread brain Assessment:
Causes: Cigarette smoking Dyspnea
Pollutants (Radon gas cemento) Dysphagia
Assessment: Weight loss
Coughing Dx: Biopsy
Wheezing Nursing Dx: Altered Nutrition
SOB Mgt:
Hemoptysis 1. Surgery – esophagectomy (portion) –
Chest pain (Pleuritic type) – upon inhalation-pain anastomosis of stomach
Hoarseness of voice Teaching – stop smoking & alcohol
Dyspnea/Dysphagia Diet: high CHON & CHO
Weight loss 2. Radiation
Mgt: Radiation 3. Chemotherapy
Chemotherapy
Surgery Gastric Cancer
Water seal drainage Risk Factors:
Alcohol
Born – type A personality (acidic- stress) Post: Bleeding prec/Right-side lying
Cured/salty foods Mgt: Surgery – resection
Dec dietary fiber Chemotherapy & Radiation
European & Japanese (Asian) Liver Transplant – regrow
Family history
H. Pylori Infection Pancreatic Cancer
Smoking Risk Factors:
Assessment: Alcohol/African American men, elderly
Anorexia/vomiting/anemia- damage parietal cells Cigarette smoking
Blood in the stool (melena) Pancreatitis
Coffee emesis High fat diet
Dec. in weight Assessment:
Epigastric pain Anorexia – malnutrition
Fatigue Abdominal pain at night
Dx: Abdominal bloating
1. Gastric analysis Jaundice
2. Gastroscopy & biopsy Dx: increased amylase – better indicator, more sensitive
Mgt.: Lipase & bilirubin
1. Surgery Mgt: Surgery: Pancreatoduodenectomy (Whipple’s
a. Billroth I – gastroduodenostomy procedure) – removal of pancreas, common bile duct, gall
b. Billroth II – gastrojejunostomy bladder, portion of duodenum, portion of stomach; CI:
CI: dumping syndrome – rapid emptying Hypovolemic shock
of stomach and inc. osmotic fluid; low Radiation
fiber &CHO, Inc fat & CHON; low Chemotherapy
fowlers or supine Drugs necessary after surgery:
c. Total gastrectomy – esophagojejunostomy Pancrealipase - replace enzyme
CI: Pernicious Anemia Insulin only
2. Chemotherapy Bile salt
3. Radiation
Colon Cancer – develop in the cell living the bowel wall;
Liver Cancer spread in the liver
Risk Factors Cause: Poor diet – inc. fatdec. Fiber
Hepatitis B & C Hereditary
Estrogen pills/OTC pills Assessment:
People: Africa/Asia Blood in the stool/rectal bleeding- common sign Ca
Asian Anemia
Assessment: Anorexia
Loss of appetite Abdominal distention
Indigestion Abnormal
Vomiting Right – Ascending colon: Watery stool (diarrhea
Enlargement for no reason)
RUQ pain Left – Descending colon: Ribbon like stool
Jaundice (constipation)
Ascites (dec albumin) Rectal: Alternation diarrhea & constipation
Hepatomegaly Management: Bowel resection and creation of
Dx: Liver biopsy – Position- left side lying, give local colonostomy- liquid initially & become formed/ Ileostomy
anesthesia – liquid or watery, lifetime, absorption of water
During: Inhale & Exhale then hold breath for 10 sec Color: beefy/brick red
Opening of pouch: 1/8 inch larger Recolapse the Jackson Pratt – apply negative
Liquid stool initially pressure
Observe for leakage Elevate affected arm/with pillow/exercise
Skin care – clean stoma with mild soap & water, Assessing BP – unaffected arm to prevent lymph
Caraya powder – prevent irritation of the skin & skin edema, no pressure affected arm
moisture Support arm sling
The consistency depends on location Turn on unaffected side only
Once 1/3 or ½ full empty Ovarian Cancer:
Mucus – expected - Grows rapidly, spreads fast and is often bilateral
You avoid gas forming/odor forming - Metastasis: pelvic organ
Gas/Odor forming food - Prognosis: poor prognosis (late detection)
Alcohol, artichokes, asparagus o Early – asymptomatic
Broccoli; Brussel sprout, beans, onion Risk Factors:
Cauliflower, cabbage, celery, corn, caffeinated Obesity
drinks, cheese, camote Vaginal use of talcum powder
Dairy products Age > 50 yo
Eggs Race: American women
Infertility
Breast Cancer – estrogen dependent; metastasis to bones Abuse of fertility – Clomid – S.E. twin pregnancy
& lungs thru lymphatic system Nulliparity
Risk factors: Assessment:
Advancing maternal age/American Women Abdominal enlargement
Breast Ca in the family Amenorrhea
Cigarette smoking Ascites
Diet: inc fat Abdominal disturbances
Early menarche/late menopause
First child after 35 yo Mgt:
Gravida - nulliparity Surgery: laparotomy, bilateral
Assessment: salphingooephorectomy, TAHB-SO
Bleeding/nipple discharge Chemotherapy: Taxol (Paclitaxel)
Retraction of nipple Radiation
Elevation of one breast Immunotherapy
Asymmetry Hormonal agents: Tamoxifen
Skin dimpling or orange peel appearance (Peau d’
orange) Endometrial Cancer: Slow growing associated with
Thickening/lump menopausal years
Dx: Risk factors:
Mammography Family history
Aspiration biopsy Infertility
Serum tumor marker (CA125) Habitual abortion
Staging; lymphangiography Obese
Mgt: Surgery: Lumpectomy – removal of lump/tumor Old age
Modified Radical Mastectomy – lymph nodes & Prolonged use of estrogen pills
tumor breast tissue Endometrial polyps
Radical Mastectomy/ Halstead – up to muscles and Estrogen: inc in level
nipple; dec fat and inc Vit Assessment:
Nrsg Care: Post-menopausal bleeding (vaginal, painless)
Bleeding or discharge monitoring Watery serosanguinous drainage
Low back/abdominal/pelvic pain Urgency
Enlarged abdomen Nocturia
Dx: Dysuria
Endometrial biopsy Hematuria
Fractional Curettage Small urinary stream/dribbling urine
Mgt: Dx: DRE
Surgery: total hysterectomy & bilateral salphingo- Tumor Markers:
oophorectomy Prostatic Specific Antigen O – 4 < 10 = BPH
Radiation >10 prostatic Ca
Hormonal agents Acid & Alkaline phosphatase
Progestational therapy: Depo-provera Mgt: 1. Hormonal manipulation – limit the amount of
(medroxyprogesterone) or Megestrol acetate (Megace) circulating androgens
S.E. Anorexia, nausea, vomiting, edema - Diethylestilbestrol (DES)
Chemotherapy - Leuprolide acetate (Lupron)
- Flutamide (Eulexin)
Cervical Cancer - Goserelin acetate (Zoladex)
Risk Factors: 2. Orchiectomy – limit production of testosterone
Alcohol (palliative)
Behavior: multiple sexual partners 3. Transurethral resection of the prostate (TURP) –
Chronic instrumentation of cervix insertion of a scope into the urethra to excise prostatic
Disease HPV tissue
Daughters of women who took: DES Health teaching: instruct no driving for 2 weeks, No
Early age of sexual intercourse/multiparity/preg heavy lifting 4-8 weeks – strenuous activity
Assessment Cystoclysis actual – output - input
Post coital bleeding
Painful intercourse
Period or menstrual irregularities Testicular Cancer
Progress: foul smelling discharge Risk Factors:
Pelvic Pain Male – 15-40 yo – Caucasian
Dx: Linked to DES
1. Pap smear Cryptorchidism
2. cervical biopsy Hereditary
Mgt: Assessment:
1. Surgery: Lump
Hysterectomy – Conization Large
2. Radiation: Intracavitary Cesium Loaded
3. Prevention: annual pap smear Leg Pain
Lymphadenopathy
Prostate Cancer – slow growing; usually androgen Dx: TSE & Inc AFP & HCG
dependent; spread spine & legs Treatment:
Risk factors: 1. Surgery – Unilateral Orchiectomy
Family history 2. Radiation to lymphatic
Age: >50 yo 3. Chemotherapy – Cisplatin (Platinol)
More common: Obese Nrsg. Intervention
African-American Can resume activities after 1 week
Smoking NO lifting > 20 lbs
Assessment: NO stair climbing
Frequency Monthly do TSE
Sutures removed: the pt come back to Dr 7-10 Painless hematuria
days after surgery Dx.: IVP & CT scan
Treatment:
Bladder Cancer 1. Surgery: Nephrectomy
Risk Factors: 2. Radiation
Cigarette smoking 3. Chemotherapy
Common: Male 4. Immunotherapy-Intravenous Interleukin
Chronic bladder infection
Chemicals: Aniline & wood dye ONCOLOGY EMERGENCIES
Contrast medium Emergency Symptoms Managements
Chronic use of Analgesics Septic Shock Dec. BP, Inc HR & Antibiotics IV
RR, fever & chills Hydration therapy
Assessment: DIC Severe bleeding Fresh frozen plasma
Frequent urination Inc Hgb, Hct, & cryoprecipitate
platelet
Painless hematuria – initial sign Prolong bleeding
Dysuria parameters
Dx: Pericardial Dec BP, CO and Inc Pericardiocentesis
Tamponade- 2D CVP, JVD, pulsus O2
Cystoscopy echo confirmation paradoxus – dec Vasopressor
Biopsy systolic BP 10
inhalation, Distant
Mgt: muffled
Surgery Superior Vena Cava Inc ICP, JVD, Diuretics
a. Cystectomy Syndrome – Periorbital edema, (furosemide)
Congestion Upper DOB, chest pain, Corticosteroids
b. Ileal conduit (urinary extremity arm & shoulder High-fowlers
diversions) – flushing edema No BP or
venipuncture Upper
anastomosis of ureters to 12 cm long of ileum extremity
- Incontinent diversion (urination is Hypercalcemia Constipation, Monitor Ca level
continuous) – inc risk DHN muscle weakness, ECG at bedside
DHN, Do hydration therapy
- Ureters to a stoma opening on abdomen Dysrhythmias
Spinal cord Initial – Paresthesia, Radiation therapy
compression- pain, altered Corticosteroids
c. Koch Pouch – continent diversion – pouch Cervical – resp reflexes
from stomach – self catheterization every 4-6 Thoracic –
hours & before sleeping ambulation
Lumbosacral – GI &
GU Sx
Tumor lysis Inc K, uric acid, Do adequate
syndrome phosphorus hydration 48 hours
Dec Ca before & after
S/Sx of renal failure chemotherapy
Acetazolamide to
alkalinize urine
Monitor electrolyte
Renal Cancer INTEGUMENTARY

Risk Factors:
Renal Calculi
Expose to Benzene & gasoline
Nephrotoxic
Asbestos
Link to hereditary
Classic triad: (late)
Palpable abdominal mass
Palpable node
Functions:
Protection Vesicle – fluid filled less
Sensation than 0.5 cm
Excretion Ex. Varicella
Temp. regulation
Vit. D synthesis Bulla – fluid filled > 0.5 cm
Ex. Contact dermatitis
Pustule – pus-filled
Ex. Acne, impetigo
Plaque – group of papule &

scaly
Ex. Psoriasis
Wheal – cutaneous edema
Gerontological Considerations
Ex. Urticaria, insect bites
Loss of subcutaneous tissue
Degeneration of collagen and elastic fibers
Secondary Lesions
Loss of melanocytes
Scales – flaky exfoliation
Increased capillary fragility
Ex. Psoriasis
Dec. secretion of sweat glands
Hormonal changes
Crust – dried crust with blood, serum, pus
Over exposure environmental elements
Ex. Scab on abrasion
Physical Examination
Bacterial Infections
Color
Impetigo – cause: staphylococcus aureus & B-hemolytic
Skin temperature
strep
Moisture
Commonly involved areas: arms, face, legs
Texture
Clinical Manifestations: fluid-filled vesicle with
Turgor
honey colored crust
Nrsg Interventions: Prevent spread – contact
Diagnostic Studies:
precaution – gloves & gowns
Skin Biopsy – sample tissue examination Dx
Maintain proper hygiene
Skin allergy testing – allergens or antigen
administered into the dermis
Viral
Skin culture – determine bacterial, fungal, viral
Herpes Zoster (Shingles)
infection
Cause: Reactivation of varicella
Wood’s light examination – viewing skin under UV
Lesion: Unilateral fluid filled vesicle with crust over
light thru special glass, identify infection
a nerve = painful & temp
Primary lesions:
Nrsg. Interventions
Macule – flat & non-palpable
Initial – isolate client – airborne
Ex. Flat moles, freckles
If crust – contact precaution- give Acyclovir –
prevent superinfection
Papules – elevated & palpable but extent is superficial
only/epidermis
Fungal Infection – ring worm
Ex. Warts pigmented nevi
Tinea pedis – foot
Tinea Corporis – body
Nodule – elevated & palpable, extend dermis
Tinea Capitis – Head & face
Ex. Lipoma, squamous cell carcinoma
Tinea Cruris – groin area 2. Psoriasis – chronic disease
Tinea Unguium – nails Cause: Stress
Nursing Intervention: Certain meds – lithium & anti-malarial agent
1. Griseofulvin: anti-fungal; oral- once a day/ S.E. Autoimmune
– photosensitive Lifestyle (smoking & alcohol)
2. Topical medications: Clotrimazole, Miconazole, You have a family history
Terbinafine X 3-4 weeks – 2x/day Epidermal cells produced at 6x to 9x faster than
3. Hygiene regimen: use own comb, brush, hats or normal
head gear Lesion: bilateral silvery scaly lesion with red base
4. Contact Precaution Nails: pitting, thickening with discoloration
o 10 % clients: arthritis
Parasitic Infection Mgt: topical therapy – corticosteroids & apply
Scabies emollients: Coal tar shampoo – most common treatment
Cause: Sarcoptes Scabiei Photochemotherapy (PUVA)
Lesion: brownish black threaded burrows/lesion Health teaching: PUVA treatment – initial 3-4x a
Treatment: Scabicide – lindane (Kwell) lotion – week, then monthly after
discourage – slow effect Psoralem & UV A – orally taken 1 hr
WOF A.E. seizure prior to PUVA; inc absorption of UV
Health teaching: Health teaching: instruct client to cover eyes cause
1. Advice client to do warm shower blindness
2. Apply lindane neck downwards, avoid neck & Groin – sterility
face allow up to 12 hours NO sun exposure post-procedure 24hours
3. Do warm shower
4. You may repeat after 1week but with Dr’s Malignant lesions
order (so Dr will assess 1st if you are qualified Basal cell Squamous Malignant
for the dose) Carcinoma cell Melanoma
5. Wash soiled linen separately - benign Carcinoma
Characteristics Waxy nodule Small, red Lesion may be
6. Expose to sunlight or fleshy bump nodular lesion white, blue,
Nursing Interventions: arising from or scaly patch gray (+),
basal cells arising from bleeding,
Secure all members of the family
keratinocytes itching
Control of itchiness/contact precaution Areas Face, neck, Upper Any part of
Anti-scabies hands extremities, the body
lips, mouth
Bed linens exposed to sun Metastasis Rare Lymphatic or Lymphatic or
Inspect other fomites blood blood.
Educate & explain drug use Metastasizes
to brain, bone,
Skin infections liver lung
Inflammatory Prognosis Good Good if Poor
detected early
1. Eczema – non-contagious
Malignant Melanoma
- Pruritus and hyperirritability of the skin
- Most common cause skin cancer death
Cause: irritation or cause skin allergy, stress related;
- Arise from epidermal melanocyte, or from existing
allergy
nevi
Allergy: red dry itchy & scaly lesion
- Poor prognosis even with treatment
Treatment: anti-inflammatory (corticosteroids -
Risk Factors:
topical) apply skin emollient
1. Exposure to UV light
Health Teaching: Advice non-contagious & avoid
2. Chronic friction to the skin
harsh substances – perfume, avoid scratching, apply
3. Exposure to irritating chemicals
mitten, cut or trim finger nails
4. Fair-skinned person who sunburns easily
5. Genetic Predisposition
Nursing Interventions: 1. Fallopian tube – site of fertilization; Muscular
1. Avoid excessive sun exposure tube
2. Report non-healing wounds 2. Ovaries – secretions of hormone; estrogen &
3. Encourage adequate nutrition progesterone; production of ovum
3. Uterus – site of implantation (happens post 7-10
days)
Decubitus Ulcer 4. Cervix – protection
- Localized area of necrosis of skin & subcutaneous Close – during pregnancy
tissue as a result of pressure Open – labor & menstruation
Risk factors: 5. Vagina – passageway – fetus, penis, menses
Malnutrition - Organ of copulation; birth canal
Immobility – common
Infection *add note: Chlamydia & Gonorrhea – risk for ectopic
Excessive skin moisture pregnancy
Equipment’s (cast/traction) PID – can lead to scarring so same Risk for ectopic preg
Advancing age Smoking – CI for women taking pills cause at risk for
Mgt: clotting formation
Keep skin dry
Turning every 2 hours Estrogen
Avoid friction Spinnbarkeit & Ferning – inc stretchability of
Wound care cervical mucus, skin elasticity
Secondary sex characteristic development
Stage Depth Appearance Eschar Purulent Inc libido
drainage Inc osteoblast & fibroblast activity
1 Intact skin Reddened None None
Inc HDL and dec LDL
(does not
blance), Inc vaginal pH (sperm survival)
returns to Inc clotting tendency
normal color
after 15-20 Inc Risk for certain cancer
mins or Na & H2O retention
pressure relief
2 Epidermis Shallow ulcer White or Not
with pink base yellow common Progesterone
3 Dermis & Ulcer may White, Common Balances the effect of estrogen
subQ have a gray or
tissue lip/edge yellow Implantation,Inc the body temp (risk for hot flashes)
4 Muscle & Deep ulcer, Brown or Common Glucose Inc. (mild glycosuria)
bone foul smelling black
Maternal and Child Nursing
G.I. function (dec) risk for constipation

Smooth muscle relaxation
(+) prevent Inc BP, dec Uterine contraction
Female Reproductive Structures (-) dec cardiac sphincter (risk heartburn)
Menstrual Cycle Normal length 3-7 days average 30-50- (80 cc)
- Purpose: prepare uterus for pregnancy of cycle – 21-40 5 days
- 1st day menstruation – start of menstrual cycle days, average of
- 1st day of the next – last 28 days
Abnormal:
Oligomenorrhea Hypomenorrhea Hypomenorrhea
– long or seldom – bleeding < 3 - < 30 cc
cycle days
Polymenorrhea – Hypermenorrhea Menorrhagia –
short and – bleeding > 7 > 80 cc
frequent days
Metrorrhagia –
bleeding in
between menses
Ovulation – mid cycle
Releasing of mature ovum (14 days before the onset
of the next menstruation; just subtract 14) +/- 2 days pre &
post
1. Spinnbarkeit – inc stretchability of mucus; thin
- 2 cycles & watery, clear & abundant
a. Ovarian cycle
• Follicular phase – days 1-14 – start of cycle up
to ovulation
• Luteal phase – 15 -28 days- ovulation to end of
cycle 2. BBT (Basal Body Temp) – affected by
b. Uterine cycle progesterone/ get the baseline temp before
• Menstrual phase – 1-5 days (bleeding) start of arising; day before the ovulation body temp will
cycle up to shredding drop to 0.5 – 1 °F, ovulation day – Inc.
• Proliferative phase – 6-14 days (thickening of Health teaching – avoid coitus for 3-4
endometrial lining) days upon noted temperature changes
• Secretory phase – 15-28 days (further 3. Mittelschmerz – lower abdominal pain coincides
thickening of endometrial lining) with rupture & during ovulation
- Start cycle
Shredding of endometrial lining (menstrual phase)
leads to dec. estrogen & progesterone which signals
the hypothalamus to release GnRH then anterior 4. Ferning – pattern (+)
pituitary gland releases FSH (Responsible for
follicular growth) then 1 follicle will mature into Contraception
Graafian follicle then there will be an inc Estrogen & A. Natural
LH (hormone for ovulation) Proliferative phase then 1. Rhythm/calendar – record 6 consecutive
Graafian follicle will rupture & release a mature cycles; determine the shortest (minus 18) &
ovum (ovulation); (the body will become the corpus longest cycle (minus 11)
luteum) so there will be an Inc Estrogen and - Regular cycle:
Progesterone (secretory phase) // corpus luteum will o 28 – 18 = 10th
degenerate called corpus albicans if there will be no o 28 – 11 = 17th of cycle – NO SEX 10th
implantation (dec estrogen and progesterone) to 17th
Menstruation
Interval Duration Amount
- NO make-up, oil, lotion, cream applied breast

(fatty tissue), waist (bending)
- If patch loose – instruct to replace immediately
2. BBT - Loose for < 24 hours - effective so no need for
3. Billing’s method – unsafe – thin & watery additional contraceptives
mucus; safe – think and ropey mucus - OK – swim and take a bath
4. Symptothermal – combination billing & BBT
5. LAM – Lactation amenorrhea method – BF 3. Mini pill – progesterone only so safe for breast
can suppress ovulation feeding mother, take same time daily
- LAM criteria: - Missed dose – take immediately
o The child must be < 6 months - Today’s dose –take as schedule
o The woman must be purely breast - Health teaching – use another form of
feeding contraception for 48 hours on top of mini pill if
o Amenorrhea there’s a missed dose
6. Withdrawal
7. Abstinence 4. Morning after pill – within 72 hours post coitus
B. Hormonal 5. IM Depo-provera (Progestin) – IM every 3 months;

1. Pills (Estrogen (inc. clotting tendency), do not massage inc absorption and shorten the effect
Progesterone) – hepatotoxic S.E.: amenorrhea
CI: pt with hypertension, heart problem Health teaching – ovulation will resume 6-18
Breastfeeding (Estrogen dec milk supply) months after cessation
Cancer 6. Subdermal – effective for 3-5 yrs
CVA Disadvantage – require surgery, keloid may form
Smoking
DVT C. Barrier
Liver problem 1. Intra-uterine Device (IUD) – prevent fertilization
Health teaching: ovulation resumes after 6 months & implantation
post pill cessation S.E.: bleeding & abdominal pain
Stop taking pills: Inserted – during menses/after delivery
Abdominal pain RUQ (liver) Caution: Period is late (ectopic preg)
Chest pain (MI, embolus) Abdominal pain
Headache Severe (HTN & CVA) during coitus
Eye changes (HTN & CVA) Infection S/Sx
Severe leg pain (+) Homan’s sign Not feeling well
2. Patch String is missing
- Wear: 3 weeks & instruct pt replace weekly & (dislodge)
for a week free patch during 4th week (free patch
– menses occur)
2. Diaphragm – prevents sperm from entering the a. Prenatal History
uterus Gravida - # of preg/check missed period
- Kept in place 6-24 Para - # preg – viability (20 weeks & up)
hours Term – 37 weeks up
- Refit after – weight Preterm – 20 – 36 weeks – different from term/
change of 15 lbs count twins and triplets 1 X 1
inc/dec; child birth Abortion - < 20 weeks
- With spermicide Living
Stillborn – dead
3. Cervical Cap – same diaphragm but easily dislodge; b. AOG – measured in weeks
keep in place; 6-48 hours
Stethoscope
Fetoscope
Doppler
4. Condom – do not use simultaneously; female/male

Made – latex condom – protect from STD c. EDC/EDD
Natural Skin – NO STD Nagele’s rule: -3 months + 7 days
Failure rate – 15% -male LMP: 1st day of the last menstruation
12 %- 22 % Female 2. S/Sx of pregnancy
- With spermicide (acidic) Presumptive Probable Positive
Breast changes (+) Pt FHT
(darkening of (+) Hegar sign 12wks- doppler
D. Surgical (Permanent) – reversal success rate – 70- areola & breast (softening of 16 wks –
80% tenderness) uterus) fetoscope
Amenorrhea (+) Goodell’s sign 20 wks –
1. Tubal Ligation – Done – cautery, cutting, Urinary freq (softening cervix) stethoscope
clamping N/V (+) Chadwick’s Fetal Movement
Health teaching – resume coitus 2-3 days Chloasma sign (bluish – with examiner
Quickening – discoloration of Fetal outline UTZ
maternal vagina)
perception of Ballottement –
fetal rebounding of
movement fetus, examiners
(20th wk) fingers
Braxton Hicks –
false contractions,
painless
2. Vasectomy – excision of vas deference but
ejaculatory duct intact – with semen, No
3. BP monitoring
sperm
Normal – 1st tri -no rise BP pregnancy
Health teaching: resume coitus after 7
2nd tri- dec slightly (placental expansion)
days instruct patient to use an alternative
3rd tri- return to 1st tri levels
contraception until 2 (-) sperm counts
Abnormal: if BP inc
1st tri- H mole
2nd/3rd – PIH/GDM
4. Weight monitoring – entire preg – 25-35 lbs
Normal weight gain
1st tri – 3 lbs – 1 lb/mon
2nd tri – 12 lbs – 4 lb/mon
PRENATAL CARE:
3rd tri – 12 lbs – 4 lbs/month
1. Assessment
5. Diagnostic tests
a. Rubella titer – measure amount of antibodies
- Teratogenic
- Result: 1> 8 immune (woman)
▪ 1< 8 susceptible
Immunization: after delivery if susceptible
- AVOID preg after 3 months post
immunization
- Allergy – egg & gelatin – components of c. Amniocentesis – done 14-16 weeks
vaccine Check genetic defect; gender of the baby
- Health teaching – avoid contact with Pre: Consent; void before procedure
children/large crowds Intra: v/s mom/FHT
Post: WOF: bleeding, infection, PROM - 1° risk
Teratogenic Infections: OK- Rhogam
Toxoplasmosis Instruct pt to stay in the facility for 30 min after
Other infections – Hepa, syphilis, HIV – no procedure
Breastfeeding
Rubella d. AFP (alpha-fetoprotein) – wks 15 – 17 weeks
Cytomegalovirus Inc AFP – fetus – neural tube defect – prevent
Herpes (CS delivery) increase folic acid intake
Dec AFP – down syndrome
Teratogenic Drugs
Warfarin e. Lecithin/Sphingomyelin ratio – N = 2:1
Ace inhibitors - For baby
Lithium - Fetal lung maturation
Thalidomide’s
Streptomycin/Steroids f. Leopold’s Maneuver – pre: empty bladder, warm
hands
Valproic Acid 1st -fundus – upper part of uterus
Iodides - Check head/butt – hard & round/soft
Rogaine 2nd – fetal back – flat & broad (FHT)
Tetracycline 3rd – engagement – immovable
Isotretinoin (for pt with acne) 4th – attitude – degree of flexion; we want to know
OHA the presenting part – OK – flex/extended
Teratogenic vaccines:
MMR
Polio
HPV
6. Activities of daily living

b. Chorionic Villi Sampling – check genetic d/o a. NO Smoking
- 8-10 weeks – done b. NO amount of alcohol is safe – lead to FAS or
- Catheter is inserted to get a sample fetal alcohol
Pre: consent, full bladder syndrome – irritable
Intra: monitor v/s & inc sensitivity to
Post: bleeding & infection stimuli; poor wake
Meds post del: Rhogam given if mother RH (-) & sleep patterns;
short nose, small chin, indistinct philtrum, thin o NO gas forming foods
upper lip o Avoid reflux – sit upright for 2 hours after
meal
c. Narcotics (downer)– avoid narcotic withdrawal 2. Constipation – release of progesterone
syndrome/neonatal abstinence – S/Sx – Inc - Mgt: inc fiber intake & OFI, ambulate (exercise)
tremors, jittery, fever 3. Heartburn – progesterone (cause)
- Mgt: Small frequent meal, avoid reflux
d. Traveling/employment – allowed that there is 4. Hemorrhoids – constipation, uterine compression on
no prolong sitting & standing – prevent rectum
complication: elevate the leg, have frequent - Mgt: correct constipation
walks Left side lying position with hips elevated
Cold compress – dec swelling
e. Sexual activity – general change but dec desire Sitz bath – inc circulation
(hormones); during pregnancy there is mucus
plug & vaginal secretions – leukorrhea which Endocrine
prevent ascending infections; avoid use of 1. Increased APG activity
tampons – Inc. risk for infection a. Inc TSH – so thyroid gland releases thyroid
hormones (SNS like)
f. Nutritional requirements – 2500 kcal/day or - Inc metabolic rate
add 300 to the regular diet; INC folic acid – - Diaphoresis
400 mcg/dL, iron – 27 mg/dL and Ca 1300 – - Palpitations
1500 mg/day - Slight enlargement of thyroid gland
b. ACTH – so adrenal cortex
g. Frequency of pre-natal visits - Inc cortisol – leads too hyperglycemia
0-7 months: every month - Inc aldosterone – leads to hyper Na & water
8-9 months: every 2 weeks reabsorption
Above 9 months: every week c. MSH – inc melanin – hyperpigmentation
- Chloasma
Physiologic Changes in Pregnancy - Expected - Linea nigra
Cardiovascular - Darkening of areola
- Inc blood vol (30-50%) – specifically plasma - Striae gravidarum
1. Inc blood then plasma inc. leads to hemodilution 2. Inc HCG – maintains pregnancy during 1st tri – risk
causes physiologic anemia: Mgt.; Inc iron – dried for hypoglycemia
fruits, green leafy veg, organ meats, Vit. C, Iron - Normal – N/V – 1st tri
supp given - Abnormal – N/V beyond 1st tri – hyperemesis
2. Uterine enlargement leads to inferior vena cava gravidarum
compression (causes: stasis of blood in the lower 3. Placental hormones – expected Inc. estrogen,
extremity – leads to ankle edema (elevate legs & have progesterone, HPL (anti insulin)
frequent walks) which inc the risk for DVT (varicose - Maintains pregnancy during 2nd & 3rd tri – Ok
vein)) causes dec venous return and so cardiac output insulin
dec = effect on fetus (cause of dec uteroplacental - Disadvantage – blood glucose inc
perfusion leads to fetal distress) mother (orthostatic
hypotension – Mgt: position – left side lying) Musculoskeletal
1. Increased need for Ca – dec. Ca = leg cramps
GIT - Mgt: Inc Ca & Vit D
1. Nausea & vomiting – HCG hormone 2. Muscle relaxation – (progesterone)
o Mgt: crackers, toast ice chips upon arising - Relax hip joints – waddling gait
o Small frequent meals - WOF: falls
3. Lordosis – Normal, but it can cause low back pain
- Mgt: pelvic rock, use low heeled shoes Developmental Events
1st month
1. Germ layer formation
Reproductive: a. Ectoderm – outermost portion
1. Amenorrhea - Epidermis
2. Estrogen - Skin
3. Chadwick’s - Hair
4. Goodell’s - Nails
5. Hegar’s - Enamel
6. Colostrum production – during pregnancy - Cornea
b. Mesoderm – middle layer
Psychological adaptation - Musculoskeletal
Emotional Reaction Rationale Management - Circulatory
1st tri Focus: Mother - Reproductive
1. Ambivalence -pregnancy crisis -allow verbalization
of feelings - Ureters
2. Denial -pregnancy not yet -focus on body - Kidney
3. Rejection changes “preg is
real” c. Endoderm – inner layer
2nd tri - Bladder
1. Acceptance Pregnancy – evident Focus: fetus - Urethra
2. Fantasy
3rd Tri - Neck
1. Fear Impeding labor & Focus: childbirth - GI
2. Anxiety delivery
2. Brain or NS development
3. Fetal heart beat but not audible
Fetal Growth & Development
4. Development of trachea and esophagus
1. AOG
a. 12th weeks – symphysis pubis
2nd month
b. 20th weeks – level of umbilicus
1. Organogenesis is complete
c. 36th weeks – xiphoid process
2. Development of placenta
3. Development of sex organs
3rd month
1. Complete placenta and barrier
2. Production of amniotic fluid
a. Source: fetal urine
2. Basis
b. Volume: 800-1500 mL = Normal
d. LMP – 1st day of the last menstruation
c. pH: 7-7.5 – alkalinic – nitrozine test – turns
e. Date of quickening – 20th week
blue
f. Fundic height (Bartholomew’s rule)
d. Color: clear
i. Pre- void
3. Audible FHT by Doppler
ii. Intra
4. Bone formation
3. Stages of development
a. Conception to 2 weeks = zygote
4th month
b. 2 weeks – 2 months = embryo
1. Audible FHT by fetoscope (16th)
c. 2 months to term = fetus
2. Visualization of skeletal outline
4. Emphasis of development
3. Human face appearance
1st tri: organogenesis
4. Development of external genitalia
2nd tri: fetal length
5. Lanugo
3rd tri: rapid growth & development of the baby
o *betamethasone – promote neonatal
5 month – fetus is at the umbilicus
th
pulmonary maturity
1. Quickening
2. Vernix B. Bleeding in pregnancy
3. Audible FHT by stethoscope (20th) - Check AOG & type of bleeding
- Bleeding leads to blood loss then dec
6th month intravascular volume which dec cardiac
1. Term size output, venous return –so dec fetal
2. Scalp hair uteroplacental perfusion leading to fetal
3. Pinkish, wrinkled skin distress// effect to the mother – dec renal &
brain perfusion leading to renal failure then
7th month death
1. Development of alveoli General mgt.;
2. Production of surfactant 1. Positioning – left side lying, bedrest
2. O2
8th month 3. IVF, blood transfusion
1. Dec lanugo and vernix 4. V/S, pad count – excessive bleeding-
2. Rapid fat deposition saturation of pad < 1 hour
3. Viable 5. I & O < 30 cc/hour
6. NO vaginal exam or IE – for placenta
9th month previa but if pt is at the OR – it’s OK to IE
1. Lanugo & vernix caseosa disappearance 7. Shock S/Sx
2. Amniotic fluid dec 1st Trimester bleeding
3. Birth position assumed 1. Abortion < 20 weeks
Types:
COMPLICATED PREGNANCY a. Induced – planned
A. Hyperemesis Gravidarum - > 1st tri i. Medical abortion – meds given
- Excessive N/V (2nd & 3rd) mifepristone (abortifacient)
- Hyponatremia & hypokalemia leads to dec ii. Surgical abortion – D&C and menstrual
cardiac dysrhythmias leading to dec cardiac extraction/suction evacuation
output and so dec uteroplacental perfusion b. Spontaneous
- Starvation/severe DHN Types:
o Mother – weight loss leading to Inc Hct, Type Description Mgt
ketonuria 1. Threatened -abortion has not yet taken -Assess FHT
place -No strenuous
o Fetus – dec fetal nutrition -No cervical dilation activity
- Comp.: IUGR, CNS malformation so preterm -with/without cramping -NO coitus for
2weeks
labor is common
2. Inevitable (+) cervical dilation & -collect tissue
- Mgt: NPO within 24 hrs, IVF – D5LR for 24 hrs uterine contraction fragments -cause of
o Antiemetics H-mole a grapelike
structure
o I&O -D&C
o After 24 hours without N/V – ok to eat, 3. Complete -all products of conception -No treatment
progress the diet to clear liquids 1st then expelled needed just provide
support
crackers, toast, cereals then soft diet the 4. Incomplete Membranes/placenta D&C
regular diet retained
5. Missed Fetus dies in utero, not Do UTZ to confirm
o If vomiting recurs – use TPN expelled D&C
▪ WOF: fluid overload, hyperglycemia, 6. Habitual 3 or more abortion Assess underlying
infection causes
2. Ectopic Pregnancy – 95 % fallopian tube
Risk factors: STI 2. Incompetent Cervix
Infection (PID) - Premature cervical dilatation
IUD - Risk:
Invetro o Inc maternal age
Fertilization o Congenital defects
S/Sx: sharp & stabbing unilateral pain at the time o Trauma (cervix)
of rupture o Bleeding painless
- Scant vaginal bleeding ▪ Color: pink-stained discharged
- Shoulder pain cause of phrenic nerve - Mgt: Cerclage – McDonalds – sutures are
irritation remove 37-38th week – NSVD
- Cullen’s sign (bluish o Shirod Kar – suture not remove – CS
tinged umbilicus)
- Abdomen can become Third Tri Bleeding
rigid
- WOF: shock S/Sx
- Dx: UTZ
- Treatment: unruptured – meds –
Methotrexate (attack fast growing cells) &
Mifepristone (abortifacient)
- Surgery: Salphingectomy & Placenta Previa Abruptio Placenta
▪ Salphingostomy – fallopian tube Risk Factors -abnormal placental -PRIO
implantation (lower -premature placental
part) separation – CS
Second Tri bleeding -Risk factor: -Risk factor:
-multi gestation -Diabetic
1. Hydatidiform mole – gestational trophoblastic -close pregnancy -Trauma
disease; grapelike structure interval; myoma -Short-umbilical cord
o Abnormal proliferation of trophoblastic villi -HTN
-Cocaine use
o Associated with chorio carcinoma Pain (-) (+) sharp & stabbing
▪ Risk factor: Bleeding Bright Dark – red (bleeding is
concealed depending on the
• Asian site)
• Low CHON intake Uterus Soft Hard/ Rigid / boardlike/
couvelaire abdomen
• Type A women who many type O Management -V/S, FHT -V/S, FHT
men -Position – LSL - LSL
• > 35 yrs old -Bedrest - bed rest
-WOF: Shock - O2
▪ S/Sx: -NO IE not unless at - Inc OFI
o HCG Inc OR - CS delivery
-< 30 % = NSVD - WOF: shock
o Hyperemesis Gravidarum -> 30 % = CS - DIC and to prevent
o HTN 1st tri this give fibrinogen
o Heart tone absent cryoprecipitate
o Height of fundus is > AOG

PRIO:
o History of past (abortion) & present
1. Abruptio pregnancy
(passage of grapelike structures)
2. Ruptured ectopic pregnancy
▪ Mgt.:
o Methotrexate
C. DIC – clotting disorder
o HCG monitoring
- Risk factor
for 1 yr
o Abruptio
o Avoid pregnancy for 1 yr
o Placental/fetal retention
o Surgery = D & C or hysterectomy
o PIH (+) pm - > 95 or 2 out of 4 are abnormal
- Excessive bleeding in 1 site, so platelet and fibrin will Mgt: modify diet (adequate glucose or
rush to site reason why there’s none enough left for maintain dec fat intake & inc fiber)
the rest of the body Exercise – dec insulin
- Mgt.: treat underlying cause requirement/Think of exercise as other insulin
o Heparin – normal, clotting function shot
o Transfuse BT – fibrinogen cryoprecipitate Med – insulin (regular/intermediate)
Avoid OHA/inc insulin 2nd & 3rd tri
D. Preterm labor Biophysical profile
- Before < 37 weeks - Normal result: 8-10
- Risk factor: underlying medical condition - Abnormal: < 8 assess further
o Infection - check fetal well being
o DHN - fetal breathing
o Stress - fetal movement
- Mgt: Inc fluid - amniotic fluid volume
o Instruct pt to rest - fetal tone
o Betamethasone to hasten lung maturity - inc heart rate
Non-stress test Contraction
E. Gestational DM stress test
Invasive Non-invasive
– HPL – anti-insulin so insulin level dec then
Management Educate mother to -Obtain consent
glucose can’t be utilized leading to inc glucose in push the button per -Ask pt to void
response liver convert glycogen to glucose leading fetal movement -Contractions
to hyperglycemia induced via oxytocin
or nipple stimulation
- Mother: inc risk for infection Duration 20-30 min 2-3 hours
- Fetus: LGA/macrosomia – CS Measures FHR acceleration FHR deceleration
related to fetal related to contraction
o Fetal hyperinsulinemia – fetus will movement
become hypoglycemic at birth Result Normal: “RN” Normal:
▪ Mgt: early breastfeeding Reactive “2-15-15” Negative – no
2 FHR acceleration deceleration
- Dx: 1. 50g oral glucose test – no fasting RN by 15 beats lasting Abnormal:
- 7am – 50g glucose given (orange juice) NST 15 seconds Positive – 50% or
-R Abnormal: more contraction
- 8 am – blood extraction CST Non-reactive – no cause of late
- Result - > 140 mg/dL – perform OGTT -N acceleration deceleration
2. 3hours fasting glucose tolerance test Mgt: Receive a Mgt: Stop oxytocin
snack to stimulate 1. LSL
(OGTT) oral glucose tolerance test the baby, then after 2. O2
NPO – 8- 12 hours the snack repeat the 3. Inc fluids
procedure, if it is WOF:
After NPO still abnormal Preterm labor –
7am – blood extraction, fasting specimen REFER have pt stay in
determine fasting value Normal -95mg/dL- facility for 30 mins
post
max, after getting fasting specimen, give
100g glucose F. Pregnancy Induced Hypertension (PIH)
8am- Blood extraction; normal value 180; - Acute hypertensive state
normal inc then do not give glucose - Inc BP- 2nd & 3rd specifically 20th week
9am -Blood extraction; normal 155 then - Cause – unknown
do not give glucose - Risk factors:
10am - Blood extraction; normal 140 o Family History
Result o Heart problem, DM, Renal Problem,
polyhydramnios
If fasting value: o Extremes in age
o Multiple gestation/multiparity II. Android – heart shape, male pelvis- CS
o Black people III. Platypelloid – CS- flat
o Obese IV. Anthropoid – NSVD, oval, ape-like
o Low socio-economic background pelvis
BP Edema Proteinuria Others B. Passenger
GDM 140/90 X X X I. Presentation
Mild pre – 140/90 Lower (+) 1 to (2) Wt gain > 2
eclampsia extremity & lbs/wk – 2nd tri Types:
some upper or < 1 lbs/wk 1. Cephalic – head
parts for 3rd tri
Subtypes
Sever-pre > Facial (+) 3 to (+) 4 n/v, epigastric
eclampsia 160/110 edema pain, visual i. Brow
disturbances ii. Face
Eclampsia ✓ ✓ ✓ Seizure or
coma
iii. Mentum/chin
Prio – airway iv. Vertex (full flexion) -ideal
Mgt: 2. Breech – buttocks, feet (complete,
- Monitor patient for 48 hours for progress incomplete, footling, frank – knees
o Bed rest extended to chest)
o Position – LSL
o Diet – maintain Na+ intake, Dec fat, Inc
CHON
o Observe seizure precautions
▪ Dim lights
▪ Room farthest
3. Shoulder
▪ O2 with suction at bedside
II. Attitude – degree of flexion
▪ Padded side rails
i. Vertex – full flexion, NSVD
MgSO4 – prev seizure
ii. Sinciput (moderate flexion, NSVD)
Toxicity – DTR (-)/Normal +2
iii. Brow (partial extension, CS)
RR dec
iv. Full (complete extension, CS)
Oliguria
BP dec
Antidote: Ca gluconate
G. Multiple gestation
- Types:
o Monozygotic – 1 ovum/placenta – identical
III. Lie – long axis of baby to long axis of
twins
woman
o Dizygotic – 2 ovum/placenta – fraternal twins
2 Types:
▪ S/Sx: ht of fundus > AOG
1. Longitudinal – spine parallel to
• Multiple heart tones each other (cephalic/breech)
• Complications: 2. Transverse – spine
o Mother: Placenta previa, PIH, Preterm labor, perpendicular to each other
Anemia, Hydramnions (shoulder)
o Baby: Low birth weight, congenital anomalies IV. Position – relationship of the presenting
Labor and delivery part to a specific part of the mother’s
Factors affecting Labor and Delivery pelvis
4Ps ______ ______ ______
A. Passage: 1st blank – determine if the presenting
I. Gynecoid – rounded, part is mother’s R/L
ideal for NSVD
2nd blank – presenting part/fetal Mirroring contraction
landmark (occiput, mentum, sacrum, Contraction then returns to
acromion process/shoulder) baseline end
3rd blank – determine if it is facing contraction
-fetal
Anteriorly-moms front/Posteriorly – compression
moms back Late deceleration Dec FHR 30-40 In order
sec after the 1.LSL
onset of UC & 2.O2
continues 3.Fluids
beyond the end
of UC
-uteroplacental
V. Station – level of ischial spine insufficiency
Zero- engage/mid pelvis, at the level of Variable Dec FHR is Knee-chest/
ischial spine deceleration unpredictable Trendelenburg
Pelvic outlet relation to UC O2
-cord Inc fluids
Crowning +4
compression Cover with
C. Power – the force that will related to cord sterile saline
expel the baby prolapse or gauze
Types: PROM
a. Primary – uterine contraction
b. Secondary – mother bearing down VEAL CHOP
Stages of labor & delivery Variable_Cord Compression
I. Onset of true labor – full cervical Early_Head Compression
Acceleration_Okay
dilatation
Late_Placental insufficiency
II. Full cervical dilatation – birth of the
baby (pushing happen so called pushing
stage)
III. Birth of the baby to placental delivery 2nd Stage
IV. Puerperium (6 weeks post-partum) Intrapartal care:
st
1 stage 1. Assessment – Mother -v/s, fetus – FHT
True labor False 2. Nutrition: yogurt & ice chips but check
Interval Regular Irregular presentation cause if breech – CS
Contraction Inc freq, duration & X
intensity *Lithotomy – risk for DVT & bleeding
Pain (walking) Inc Dec (relieve) 3. Comfort measures
Cervical Dilatation & effacement None a. Position – Squatting on all fours, semi-
changes
Phases of labor (No need to familiarize all Just the middle) fowlers/semi sitting
b. Sacral pressure – relieve low back pain
Latent Active Transitional
Dilation 0-3 cm 4-7 cm 8-10 cm c. Effleurage – relaxation
Frequency Every 5-10 Every 3-5 min Every 2-3 min d. Breathing technique
min
L-chest breathing
Duration 20-40 sec 40-60 sec 60-90 sec
Intensity Mild Moderate Strong A-abdominal breathing
T-pant-pant blow
FHR Variabilities e. Encourage voiding every 1-2 hours
FHR Pattern Description Nursing f. analgesics
Intervention Nubain/demerol – 2-3 hours before
Early deceleration Dec FHR at the Continue to delivery to prevent complication which is respiratory
onset of the monitor – depression; Antidote: Narcan
Uterine normal g. Anesthesia
- Pudendal block – episiotomy incision to Lift just the presenting part avoid
shorten the 2nd stage & prevent laceration manipulating the cord
- Epidural – side lying O2 at 10 L/min
o WOF: hypotension – LSL, O2, Inc Cover sterile saline
fluids Notify the Dr
- Spinal – sitting with back arch
o WOF: hypotension & spinal headache B. Rh incompatibility
so flat on bed 10-12 hours post op - Mother – Rh (-)
without pillow and avoid elevation o Exposure: after delivery, after abortion, after
cause of bleeding and respiratory amniocentesis, after CVS, after puncture,
depression after trauma
o Dx: Comb’s test – check if mother develop
Cardinal movements of labor: an antibody; done 1st prenatal visit, 2nd 28th
Engagement week; Normal is zero/negative
Descent o WOF: Erythroblastosis fetalis – severe form
Flexion anemia for the 2nd baby cause the mother
Internal rotation develop an antibody that attack the D -
Extension antigen
External rotation - Baby – Rh (+) – cause baby have D-antigen
Expulsion o Rhogam – passive immunity
o Administer rhogam on 28th week & within 72
3rd Stage hours after exposure or when bleeding or
Signs of placental separation trauma occurs
Lengthening of the umbilical cord
Sudden gush of vaginal blood
Change in uterus shape
Firm contraction of uterus
Appearance of placenta at vaginal opening
Presentation of placenta:
1. Shinny Shultz – fetal side = separation at the center
2. Dirty Duncan – maternal side = at the edges
4th Stage:
Involution – return to its non-pregnant state
1. Uterus – check if it contracts & firm – to prevent
bleeding
- After delivery – in between the umbilicus &
symphysis pubis
Labor and Delivery - 1 hour up to 24 hours at the level of the
A. Prolapsed cord umbilicus there is a dec 1 fingerbreadth per day
Risk factor- & 9-10day uterus is non-palpable
a. PROM – bed rest 2. After pains – abnormal if severe – assess further &
b. Placenta previa refer
c. Cephalopelvic disproportion 3. Lochia – abnormal: foul smelling & large clots
d. Hydramnios Pattern Duration Color
e. Breech presentation R- rubra 1-3 days Dark red
Mgt: Emergency S – serosa 4-9 days Pink to brown
A – alba 10 and up White
Knee chest/tren
4. Onset of ovulation
a. Breastfeeding –6 months - Methergine, Pitocin (contraction)
b. Non- breastfeeding – 6-8 weeks - hysterectomy
5. Onset of menstruation iii. Lacerations
a. Breastfeeding – 3-4 months 1. Cervical – Mgt: repair
b. Non-breastfeeding – 6-8 weeks 2. Vaginal – Mgt: repair & vaginal packing;
6. Abstinence – 3-4 weeks to prevents cervical & flag the chart cause it must be remove 24-
vaginal infection 48 hours prior to discharge
7. Contraception – barrier method (BF mother) avoid 3. Perineal – Mgt: repair, inc fluids, stool
pills softeners
- Non-breastfeeding – Ok pills iv. Uterine Inversion – uterus turns inside out – this
is an emergency leads to severe bleeding
Psychological Adaptation MD/midwife – manual replacement
Stage Duration Feature Management Anesthesia,
Takin-in 1-3 days Focus: Self, Focus: Mother, antibiotics
passive, assist ADL’s Tocolytics
dependent
O2/v/s/standby CPR
Taking 4-10 Focus: Focus:
hold days Baby, Newborn IVF, BT
readiness to teaching, CS for future
learn ideal time pregnancy (no NSVD)
Health
teaching,
Letting go 10 days Focus: new Support
up role guidance
Other normal Changes:

b. Late- > 24 hours
- Blood – dec Hct & Hgb
- Retained placental fragments – usually 6-8 days
o Normal 4 pts, 1 gm/250 ml blood loss, if
o Mgt: D & C
NSVD – 300-500 ml for CS – 500-1000 ml
▪ Methotrexate – destroy retained
o Inc WBC – defense & healing, Inc fibrinogen
fragments
– risk for DVT
▪ Health teaching: monitor lochial
- Temperature – Normal inc within 1st 24 hours
bleeding
o Normal 100.4 °F (38°C) cause of DHN
Others:
- Diuresis – normal inc urine output – 3L/day up to 5
- DIC
days
- Sub-involution – incomplete return of the uterus to its
non-pregnant state
Post-Partal Problems
o Mgt: methergine, Breastfeeding, ambulation
a. Post-partal bleeding
- Hematoma – collection of the blood in the subQ layer
1. Early
of the perineum; painful
ii. Uterine atony
o Mgt: ice pack in a towel, analgesics & inc
Risk factor:
size of hematoma – surgery: incision &
- Prolonged labor
ligation of blood vessels
- Inc maternal age
- Deep anesthesia/analgesia
b. Postpartal Infection
- Bladder full
- Puerperal infection – infection along the reproductive
Mgt:
tract
- Uterine massage until
Predisposing factor: PROM, trauma, local
firm
vaginal infection
- Void every 4 hours
Mgt: Fowlers
Antibiotics 1. Infertility (subfertility) – inability to conceive for
Change pads regularly 6 months if the mother is >35 yo; 1 yr < 35 yo
Sitz bath - Check potential pregnancy
o Primary infertility – no previous
- Endometritis pregnancy
o S/Sx: o Secondary – (+) previous pregnancy
▪ Fever ▪ Mgt: treat the underlying cause
▪ Body malaise • If dec hormones – give clomid –
▪ Chills stimulate ovulation; S.E. multiple
▪ Pain/abdominal tenderness gestation
▪ Soft uterus • Endometriosis – give Donocrine,
Mgt: Same: FAC only then give Lupron
methergine no sitz bath • Infection- give antibiotics
- Thrombophlebitis 2. PID- pt have STI

o DVT - IUD use
o Pre-disposing factors: - S/Sx:
▪ Inc Fibrinogen o Pain in the lower abdomen
▪ Inactivity o Purulent discharge
▪ Smoking o Inc WBC
▪ Obese o Inc ESR
▪ Extension of endometrial infection o Develop spotting
o S/Sx: - Mgt: antibiotics, coitus during menstruation,
▪ (+) homan’s sign: redness, swelling, avoid coitus with an infected partner
warmth STI
▪ Prevention: early ambulation Infection S/Sx Mgt
o Mgt: Chlamydia Discharge: grayish white, Tetracycline/
(common) vulval itching doxycycline
▪ Elevate affected extremity
Erythromycin – for
▪ Warm compress to inc circulation preg
▪ Anti-embolic stocking Gonorrhea Discharge: yellow-green, Ceftriaxone
(common) possibly asymptomatic Doxycycline
▪ No ambulation/massage if present Amoxicillin
Syphilis – Painless ulcer 1°chancre, Benzathine penicillin
c. Breast discomforts teratogenic non-itchy/painless
2°flu-like Sx next latent
Discomfort Assessment Management next No Sx
Engorgement Pain, fullness BF mothers- regular, 3°Gumma, heart, CNS
warm compress, breast affectations, not
pump, massage, BF bra contagious, tumor like
Non-BF – cold compress, lesion
tight bra, binder Genital Herpes Painful pinpoint vesicles Acyclovir (Zovirax)
Sore Nipples Cracked Water & mild soap (type 2) – – if life threatening
Position baby slightly virus; CS Bathing with dilute
different for feeding NaHCO3
Vit E lotion, drops of milk Analgesic
Airdry Trichomoniasis Discharge: cottage Metronidazole
Mastitis Infection Dicloxacillin, - Fungal cheese like (flagyl)
cephalosporins safe for Candidiasis Discharge: cottage Nystatin (mycostatin)
BF cheese like Fluconazole
Check BF – abscess Risk Factors: (Diflucan)
Alternative: breast pump, immunosuppress,
bottle feeding antibiotic treatment (long
term), Pregnancy, DM,
oral contraceptives
Female Reproductive System Disorders
Pubic lice Black/blue spots-eggs/ Permethrin (elimite)
“crabs” bite marks Lindane (Kwell)
Genital warts Condyloma – cauliflower Sitz bath, pap smear,
(HPV) like lesions Gardasil – to prevent
cervical Ca
Newborn Care:
Prio:
1. Airway
2. Thermoregulation
3. Bonding
4. Proper identification
Criteria 0 1 2
Appearance Blue - Body-pink, Pink
(color) cyanotic extremities
blue =
acrocyanosis
Pulse (HR) Absent <100 bpm >100 bpm
Grimace Absent Grimace Strong cry
(reflex present
irritability)
Activity Flaccid Some Flexion Well- flex
(muscle tone)
Respiratory Absent Weak cry Strong cry &
effort good cry
Apgar scoring
Score Mgt
7-10 Baby is adjusting well
4-6 Airway clearance & O2 Administration
0-3 Resuscitation
Newborn Medications
Medication Purpose Site of administration
Erythromycin DOC to prevent Inner to outer canthus of
ointment gonorrheal & OU – ointment
chlamydial Drops – lower
infection conjunctival sac
Hepa-B 1st dose – within 12 IM – anterior lateral
vaccine hours after birth vastus lateralis; middle 3rd
of thigh
Vit K Within 1 hour of IM – anterior lateral Few from Mark K

life vastus lateralis; middle 3rd
of thigh Levels
A- Yes, it is abnormal and has a presence of dse but
Not a priority & you do nothing, low prio
B- It is abnormal, but you can ignore it or you don’t
have to be concerned
C- You do nothing about it all night long and dr find
out in the morning you are in major trouble
D- It is the highest prio
A B C D
Inc Crea Hgb- 8-11 > 4 INR >K=6
AbN HCO3 > HCT <K/>K < 6 pH
> BNP = > 100 < 8 Hgb > 60 CO2
AbN Na+ CO2 > 50 PCO2 < 60
AbN RBC PO2 < 78 pH < 40,000
< 93 O2 Sat-adult
< 95 for pedia
AbN Na+ - dec LOC
< 500 – ANC
< 200 – CD4 Trough- drugs at its lowest
pH < 90,000
Peak- drugs at its highest
*2 steps… Step 1: ask yourself, is it an Upper or TAP levels
Downer Step 2: ask yourself, is it an Overdose (too Trough levels – draw your trough before the
much) or Withdrawal (not enough) administration
Administer your drug
If they say: “overdosed on an upper” (too much Peak levels– draw your peak, after the administration
upper)… pick inc things
Drug toxicities
If they say: “downer & intoxication” (too much *Lithium (go Low)- common anti /bipolar drug, thera.
DOWNER)… pick dec things level 0.6-1.2 toxic level >2
*Digoxin (Lanoxin) go Low- a-fib and CHF thera. level 1-
If they say: “withdrawal downer” (don’t have enough 2 toxic level >2
downer; too little!) *Aminophylline/ theophylline – technically not a
bronchodilator – just relaxes a spasm so given before a
Too little downer makes everything go up.. Too little bronchodi/ thera. level 10-20 toxic level > 20
upper makes everything go down.. *Dilantin/phenytoin – seizure thera. level 10-20 toxic
level > 20
Upper overdose LOOKS LIKE downer withdrawal… *Bilirubin (waste product) – test in newborns elevated
Downer overdose LOOKS LIKE upper withdrawal… level 10-20, <13 not subject for hospitalization- sunlight,
14-15 think hospitalization half way toxic they can die
Aminoglycosides- A MEAN Old “-mycin” when you toxic level > 20// adult N 1.4-2.3
have a MEAN Old infection- major class that you draw *kernicterus- bilirubin in the brain (condition), around 20,
TAP aseptic(sterile) meningitis/encephalitis
- Treatment for Resisted, Serious, Life-threatening, *jaundice- bil. in the skin
Gram negative infection *opisthotonos – position the baby assume when the baby
- Except Erythromycin, Azithromycin. has kernicterus, baby hyperextend due to meningitis,
Clarithromycin – if there is a thro throw it away medical emergency
not included *In what position do you place an opisthotonos- side
- 2 Toxic Effect – “-mycin” think of mice (mickey *physiologic jaundice – appears yellow 2nd and 3rd day
mouse) think of ears and they are Ototoxic, *pathologic jaundice – high & yellow at birth -
monitor hearing, vertigo, dizziness, tinnitus, next something is wrong
is human ears connected shape like a kidney so
Nephrotoxicity- creatinine the best indicator of Guessing Use with CAUTION!
kidney function #1- 24 hour crea clearance *Psyche – nurse examine their own feeling about
serum crea #2 , number you draw in the ear is 8 something – so no countertransference
toxic to cranial nerve # 8 and administer every 8 *Psyche – establish a trust relationship
hours via IM or IV not p.o. not absorb in the gut
*Nutrition- select chicken next fish
it will be excreted so no systemic effect
*never mix medication in children food
- Except 2 cases use oral mycin (bowel sterilizer
*before mixing anything ask permission
neomycin and kanamycin) “who can sterilize my
bowel = neo kan” *toddler- finger foods
- Oral mycin-1st hepatic encephalopathy – *pre-schooler -leave them alone
ammonia gets too high, so goal is to eliminate *if you know the drug but you don’t know the S/E – pick a
ammonia– so use p.o meds for excretion & will S/E in the same body system where the drug is tested
also not hurt the liver since it will not be absorbed. *if p.o. select GI
And 2nd pre-op bowel, The # 1 producer of * never tell a child that medicine as candy
ammonia-E coli *OB – check fetal heart rate
*med surg- LOC, establish an airway
*ABCs
*pediatric skills – growth and dev = always give the child
more time to dev
When in doubt call it normal – growth and dev
only
When in doubt pick the older age
Choose the easier task
*if you know what a drug does, but not the side effects -
how do you proceed?! *great guessing strategy: pick a side
effect in the same body system where the drug is
working…
*if two answers is opposite one is probably right
*use knowledge – if you don’t know reread the question –
eliminate/pull out what you don’t know and reread
*do not delegate to family safety responsibilities not
unless you document in the chart that you teach them and
Ok competency
*Staff management: intervening inappropriate behaviors –
tell supervisors, confront them and take over immediately,
at a later day talk to them, ignore it- never an answer.
*Ask yourself- what they are doing illegal --- tell
supervisor// if not illegal-ask yourself is the pt/staff in
immediate danger of physical or psychological harm =
confront them and take over immediately // if illegal
and harmful – confront 1st then call sup// nobody is
harmed – if not the too just simply inappropriate –
approach them and talk to them
* N values P -2.7- 4.5 mg/dl
PCWP - 8-12 mmHg Mg - 1.5-2.5 mEq/L
CVP - 5-10 cm H2O ABG
- 3-8 mmHg pH – 7.35 – 7.45
Pulse Pressure – 40 mmHg paCO2 - 35-45 mmHg
HCT – Female - 35- 47 % HCO3 – 22-26 mEq/L
Male -42 – 52 % paO2 – 80-100 mmHg
HGB – Female - 12-15.5 g/dL SaO2 – 95-100 %
Male - 13.5-17.5 g/dL *Complications:
Basophil – 0-1 % (parasitic/allergic) CAD – hemorrhage
Eosinophil – 0-3 % (parasitic/allergic) Respi Acid: Respi Paralysis
Monocyte – 3-7% (severe infection) Radiographic – Anaphylaxis
Lymphocyte – 20-40 % (Viral) Endoscopy – Perforation
Neutrophil – 50-62 % (bacterial) PVC – V. Tach
WBC – 5,000-10,000 mm3 CAD – MI
Platelet – 150,000-400,000 mm3 Coronary Arteriography – Hemorrhage
Residual Vol. NGT feeding < 100 mL/hr *PRIO
Chest tube drainage - <100 mL/hr Compartment syndrome –Pain
USG – 1.003-1.030 DI - BP
PT - 12-15 sec/ 9-12 sec SIADH-BP
= cerebral edema - LOC
APTT - 16-25 sec/ 20-36 sec
Respi Acidosis = MS, MG, GBS, ALS
BUN - 10-20
TPN = Infection (sterile)
CREA - 0.6-1.2 Artificial Pacemaker – dizziness
BNP- <100pg/mL = sign - decrease cardiac output
Clotting time – 5-10 min Angina – check BP (Before, during, after)
V/S temp-oral -36.1-37.8°C / 97 – 100° F MI – chest pain
Axilla - 1° lower Antilipidemic – muscle weakness
Rectal - 1° higher = Sign- Rhabdomyolysis
RR – 12- 20 bpm Coronary Arteriography – S/Sx shock
PR- 80-100 bpm Adm Digoxin – HR & PR – 1 full min
QRS complex- 0.06 - 0.10 sec
PR interval – 0.12-0.20 sec *Antidotes
Digoxin = 0.5 -2 ng/dL Digoxin – Digibind
Folic Acid – 1.8 – 9 Morphine SO4 – Naloxone (Narcan
Vit B12 – 200-400 Thrombolytics – Aminocaproic Acid (Amicar)
Lithium = 0.6-1.2 mEq/L or mmol/L Anticoagulant
Albumin (normal: 3.5-5.0 g/dL [35-50 g/L] Heparin (IV) – Protamine SO4
Troponin T = 0.1 – 0.2 ng/mL Warfarin (PO) – Vit K
ESR - <30mm/hr Enoxaparin (SQ) –protamine SO4
HDL - > 45 (male) > 55 (female) InC Mg – Ca gluconate
LDL - < 130 mg/dL *Drugs
Total Cholesterol < 200 mg/dL Beta- blockers - “-olol” – check BP
Triglycerides- 40 – 160 mg /dL (Male) Ca-channel blockers -“-dipine” - check BP
35-135 mg/dL Anti-Lipidemic -“-statin”
Electrolytes – notice the # Fibric acid Derivatives - “fibro/fibrates”
Na+ - 135-145 mEq/L Thrombolytics -“-kinase””-phase”
Ca+ - 4.5- 5.5 mEq/L // 8.6-10 mg/dL ACE inhibitors -“-pril”
K+ - 3.5 – 5.1 Proton- pump inhibitors - “-zole” stomach .acid
ARB –angiotensin Receptor blocker – “-sartan”
= given if pt can’t tolerate “pril drugs” • Goans - GIT – constipation
A1 adrenergic Blocker - “-zocin” Mg = impulses
MAOI- antidepressants • DTR (-) or absent
• Respiratory –
*Opposite
DI = Polyuria SIADH Oliguria • Oliguria
Na Na • bP decrease
HCT HCT
H2O ab./ ADH ADH Heart – V. Tach – polymorphic
BP, weight loss, USG BP, wt gain, USG Torsades de pointes
MI Mgt
Morphine SO4
Addison’s Salt, Sugar & Sex Cushing’s Oxygen
Cause: hypoglycemia hyperglycemia Naloxone (Narcan)
A: NaH2O A: NaH2O Aspirin
K+, H+ K+, H+ Digoxin toxicity
Visual disturbances
*Drug of Choice / Mgt Anorexia
K+ - Kayexalate N/V
K+ - Kalium Durule Diarrhea
Na+/SIADH - Demeclocycline Abd cramp/pain
Na+/DI - Vasopressin/Desmopressin Right sided-heart failure
Ca+ - IV Ca+ gluconate/Ca Morphine
Chloride/carbonate O2
Ca+ - Calcitonin (blood-bone) Rest: high fowlers
- Fosamax – bone Foley cath
Mineralization fUrosemide
Mg - MgSO4 IV/Mg Salt p.o. NTG
Mg - Ca+ gluconate ACE inhibitor
Inflammatory heart dse – penicillin/vancomycin An hour before meal
- corticosteroids refer Cough (dry, persistent, irritation)
Anaphylaxis - Epinephrine refer Edema eyes & face/elevate
*Drugs/ Mnemonics
K+ = impulses Statins (HMG-COA reductace inhibitor) antilipidemics
K+ wasting diuretics Teratogenic
Bumetanide (Bumex) Low LDL
Furosemide (Lasix) – loop diuretic Increase HDL
Hydrochlorothiazide Pm/@ night
Mannitol – osmotic diuretic Increase cholesterol synthesis 12pm-5am
K+ sparing diuretics Do- increase function test (hepatotoxic)
Spironolactone -annual exam (cataract) = report: Mus. Cramps
Amiloride *Concepts Inhibitory
Triamterene Anxiety GABA
Alzheimer Acetylcholine
Ca – impulses
• Bones - Ca+ cause it’s in the blood Depression
• Stones – renal calculi Excitatory Inhibitory
• Moans – muscle weakness Norep MAOI
Serotonin
Manic SVT (supra ventricular tachycardia)
Norep Stable – DOC
Serotonin Adenosine
Intracellular Na+ Beta blocker
Ca+ channel blocker
Alcoholism & Bulimia Nervosa Unstable = cardioversion
Serotonin
Ventricular Rhythms
Schizophrenia 1.Premature Ventricular Contractions
& Dopamine DOC: Na+ channel blockers
Lidocaine/Amiodarone
*Distorted EGO O2 sup
Psychosis - no reality Refer for 3 consecutive PVC
Schizophrenia – no balance 6 inches a min (intermittent)
Ambivalence Schizophreniforms = long term 2. Ventricular Tachycardia
DOC – MgSO4; Lidocaine
Schizoid Personality Schizotypal Unstable: Defib & Cardioversion
D.O. P. D.O 3. Ventricular fibrillation
loners eccentric Defibrillation
naturally detach magical thinking; Epinephrine
very superstitious Amiodarone Lidocaine
Superego MgSO4
OCD Antisocial 4.Asystole – CPR
Depressed DOC – epinephrine
Anorexia Ready – Defib
ID Heart Blocks – DOC = atropine SO4

Manic Anhedonia Permanent – pacemaker
Antisocial
Narcissistic PR interval Prolonged (> .20 sec)
Addiction
Constant (same) Variable (irregular)
*ECG Sinus Rhythms P:QRS reset(another PR interval)
Sinus Bradycardia – Stable – DOC = Atropine SO4
PRIO – unstable/emergency – transcutaneous P=QRS P>QRS with reset without
Pacing 1°AV block 2nd°type II nd
2 °type I 3rd ° heart block
Sinus Tachycardia – Stable- DOC = beta blockers & Mobitz II Wenckebach complete HB
“olol” & “dipine” Ca+ Channel blockers without cycle Mobitz I with
cycle
Atrial Rhythms
Atrial flutter = DOC – stable – Na+ channel blockers FVE - CHF
Quinidine & Procainamide L- Lungs R- Systemic
Unstable – cardioversion - Pulmonary edema - Generalized edema
Atrial Fib = DOC – stable - Na+ channel blockers - Crackles/rales - Ascites
Thrombolytics - DOB/coughing - Weight gain
Anticoagulants
Antiplatelets Addisonian Crisis
Unstable- cardioversion - Hypotension, Tachycardia, Tachypnea
Anorexia Nervosa *Ibuprofen (NSAIDS) – occult bleeding
Serotonin *the charcoal absorbs the poison & forms a compound that
doesn’t hurt your child
*Risk for Respiratory Disorder *Trache – obturator
- Elderly Resuscitation
- Respi disorder Tracheal dilator
- Opioids Extra trache
a. Non-opioids (NSAIDS) *neutropenic – no milk
b. Weak opioids – codeine *Hirschsprung Dse
c. Strong opioids – morphine Megacolon
Aganglionic
*Spinal fusion – fuse two bones to avoid mov’t Ribbon like stool
*Bone graft more painful than a spinal incision *easy to digest- in order
*Flaccid bladder – Clear fruit juices
Crede’s maneuver – apply manual pressure to the Orange juice
lower abdomen (urge incontinence) Scrambled eggs
*Asthma- get current peak flow reading 200, baseline is Banana
480 Moist, tender meats
Green – 80-100 % = long term meds Vegetables
Yellow- 50 – 79 % = short acting bronchodilator *jejunostomy tube – continuously in small amounts
Red - < 50 = open airway, short acting bronchodilator *bladder training – urge incontinence
(albuterol) + steroids ; emergency – notify DR *measles – photophobic
*fecal impaction- oozing liquid stool ✓ Dim light
*alprazolam- sudden cessation Avoid aspirin- Reye’s syndrome
- rebound insomnia + nightmares *Corticosteroid – GI irritants
*small children- 1.0 mL IM - milk and meal allowed
Adult- 5 mL - cause Ca+ absorptions
* Birth to 1 month Hepa B (for this moshi moshi anone song all red) - with cataract
2, 4,6 months DR HIP - CI to pregnant ct. – low but teratogenic effect
D- DTAP - Inc. Sugar – may lead to insulin resistant
R- Rotavirus - Inc. Salt – fluid excess
Hib – haemophilus influenzae - Inc. Sex hormone – hirsutism
IPV- polio vaccine * Insulin open- regular insulin
P-Pneumococcal - stored in room temp for 30 days
12-15 month MMR - standard meds GDM – review insulin peak
Varicella *Glipizide (Glucotrol)- avoid oral insulin, used when beta
Hepa A cell function is present
* PTU desired effect - T3 & T4
*Case manager – do not provide direct care * Lugol’s Sol. CI prior to thyroidectomy
Cost is a concern - Iodine toxicity- abd pain, diarrhea, metallic
*Bicep reflex- nurse places her thumb on the muscle inset taste, mouth, throat pain, seizure
in the antecubital space and taps the thumb briskly with the - Shrinks thyroid gland
reflex hammer * Disulfiram reaction – headache, flushing, vomiting
*Digoxin- improved RR & increase Urinary output (heart * Cephalosporin – Diarrhea
failure) * Alprazolam (Xanax)- for anxiety
*pulseless dysrhythmias = risk renal failure so check urine - inc focus, so pt can read
output * Haldol – teach – use sunglasses & sunscreen
*RR- 10-24 - HOLD – Fever
- Fatal Comp – neurolyptic malignant syndrome *K+ - no pee – no K+ so damage kidney no K+ adm
- Fever Check BUN & Crea
- Alteration of LOC *Phenazopyridine (Pyridium) – analgesic
- Muscle rigidity / cramps - take with food to dec gastric irritation
- Autonomic dysfunction – unstable BP - red- orange urine – normal
* Lithium Carbonate(Lithonate) – mood stabilizer, manic *Sulfisoxazole – for UTI
- Intake salt - excretion - effectivity - include in teaching avoid cranberry juice while
- Intake salt - excretion - Toxicity taking the drug
Vomiting - form sulfa crystals
Ataxia * Cisplatin (Platinol) + mannitol – to dec. nephrotoxicity
Nausea & ototoxic
Almost all toxicity these Diarrhea * If with renal failure avoid Maalox- inc Mg.
Are present Abd pain *Theophylline – 8 am , 4pm & midnight
*Carbamazepine (tegretol) - myelosuppression - time- release capsule if none make sure it has
- hepatotoxic same interval or equal
* Sinemet – take this by evening/pm but no levodopa *Ipratropium (atrovent)- cross allergy
anymore, you can take it as long as its less than 8hrs Atropine sulphate
* Mestinon- (+) clear speech *too much vit C – lead to diarrhea so Vit C
* Phenobarbital (Luminal)- check v/s 1st RR *leflunomide(arava)- Rheumatoid arthritis, anti- inflame
* Nitrate – Nifedipine - BP *HIV- tx lamivudine (epivir) - prophylaxis
* Digoxin – (+) effective , clear breath sounds * prophylactic drug TB – isoniazid (INH)
Contractility Cardiac output Rifampicin
Heart rate INH
* TPA - Clot busters Pyrazinamide
* Furosemide – Comp / Na+ Ethambutol
* MI – no straining Streptomycin
* Epogen – mgt anemia 2◦ to zidovudine
* Report – Hct > 36 % might lead to hypertensive crisis hePatotoxic
Therapeutic RifamPicin
Always present when I took my exam Red-orange body fluids
* PT – 9-12 sec - < 30 sec
INR – 2-3 - < 4.5 IsoNiazid
PTT- 20 -36 sec - 60-80 Nervous system + liver reactions
CT (clotting) – 5-10 min - 16 – 20 min So report Paresthesia +
SGOT(AST) & SGPT (ALT)
*HT for pt taking (Retrovir) zidovudine
- return every 2 weeks for blood counts Arthralgia
* Griseofulvin (Grisactin) antifungal affects hair & nail PyrAzinamide
- photosensitive hepatotoxic
- wear sunscreen whenever there is a sun
exposure EthambutOl
-with or after meals bind fat, aids in absorption Optic neuritis
* tetracycline HCL (Achromycin V) – can vulgaris
- photosensitive
- avoid milk and dairy products = dec absorption Nephrotoxic – BUN & Crea
- interfere with absorption sucralfate (carafate), StreptOmyciN
this will prev ulcer Ototoxic – tinnitus / deafness
*Peak – active level of drug within the body
Through – weakest Visual disturb.-toxic so shift to other drug
Optimum time for the drug- Immediately before Onco drug so do not give if patient
the next dose OnCoViN- can’t identify (visual loss)
*Peak – oral – 60 min N/V
*IV meds – 30 min Constipation and check
*Superinfection- infection on top of the other infection Vein for extravasation
- Complicate antibiotic therapy Optic neuritis
*Allergy penicillin- cephalosporins (cross allergy)
* bone marrow suppression – platelet count
* CI – tetracyclines – enamel erosion, hypoplasia, Alopecia, N/V
discoloration of the permanent teeth, CI for children >8 y.o CytoxAN
*Ampicillin Sodium (Omnipen) – Rash- Report Cystitis & hematuria
*Histamine – PNS = bronchoconstriction & hypotension Zofran – Ondansetron – anti-emetic
oTotoxic – are you hard of hearing? H2 antagonist- bed time
GeNTamyciN Hydrochloric acid inc at night
Nephrotoxic *Ranitidine – no pain, 4 hours post given
Neurotoxic *Reglan- Parkinson’s like A/E
*Loperamide (Imodium)- ask the mother when child last
*Vancomycin- prophylaxis for endocarditis voided, GI activity/SNS
Maybe adm. p.o. or IV *aspirins tinnitus- toxic
*Ticarcillin disodium (Ticar)- lead to *Idiosyncrasy- unexpected reaction to a drug that occurs
hypothrombinemia(petechiae)= REPORT the 1st time it is given
-for pseudomonas pneumonia *Never mix medication in children food
*Antidote - Toxicity
Runny Nose Acetylcystene -Acetaminophen
heROiN Physostigmine -Anticholinergic poisoning
Protamine SO4 -Heparin
*Cystic fibrosis- nutrition Succimer -Lead poisoning
- mix pancrealipase (Cotoxym S) cap with IV 0.4-2 mg PRN -Dose naloxone opioid
applesauce before each meal poisoning (adult)
* Nystatin- spread mouth patient cannot swallow Flumazenil -Benzodiazepines
*Poison Control – CI =induce vomiting < 1y.o. Deferoxamine -Iron
- recommend vomiting for acetaminophen Pyridoxine -Isoniazid
ingestion (hepatotoxic) Activated charcoal -Therapeutic agent-universal
* terbutaline Sulfate- tocolytic action antidote
* active phase labor – Adm of Demerol (meperidine) Benzatropine -drug induces mov’t disorder
- fast onset short duration Penicillamine -Copper, gold, lead, mercury
*Observe rate and depth of patient’s respi – PCA
or patient controlled analgesia *pancrelipase – aids absorption of fats and CHON
*Fentanyl –if not effective- pain *clinical Mx of acute epigastric pain – intervention
-so notify the dr to inc dose facilitate relief of pain
*Severe cirrhosis – dev hepatorenal syndrome
N/V Mx . weight gain of <1lb/wk
Myocardial toxicity *Oliguria & Azotemia – occurs abruptly as a result to this
ADriaMyciN condition
Diarrhea *Prio for acute pancreatitis- maintain fluid & electrolyte
Alopecia balance
*Congenital Rubella syn – PDA, sensory neural deafness Condition Position
*measles- photophobic – dim light, avoid aspirin – can Arterial disorders - Dependent position (low)
cause Reye’s syndrome Venous disorders - Elevate
*neuromuscular junction ICP - Semi-fowlers and head neutral
Dopamine - Inhibitory COPD - Fowlers
Acetyl NGT insertion - Fowlers
*Huntington- genetic
- Parents, genes, counselling
*Autonomic Dys- nasal stuffiness & inc BP NGT feeding/Suction - Semi-fowlers
*Humming sound – Meniere’s Radiographic
*Symmetrel – Dopamine in CNS is Barium swallow - Fowlers
* MG – avoid Flexeril Barium enema - left sims
*CN7- ask to close client’s eyes tightly Iodine (IVP) - Supine/Flat on bed
*CN12 – Ask the client to stick tongue out Endoscopy
*Spinal cord Injury- WOF – AD & check BP EGD - Left lateral
*Bethanecol – use to tx urinary retention CI MG cause Colonoscopy - Left lateral
cholinergic crisis Sigmoidoscopy - Left lateral
*Hyperthyroidism- my chest hurt (pain) when I was Bronchoscopy - Supine
sweeping the floor
*boiled food – hyponatremia
*eggnog- alcohol beverage
*glycosylate hgb – N 4.5
*Paresthesia – 1st sign
Pain- unrelieved by meds
Pallor
Pulselessness
*Thirst preg- GDM
*preg- Normal physiologic anemia
*hydatidiform mole S/Sx – 2nd week
*H -CG
-yperemesis gravidarum
-TN
-t of fundus >AOG
-eart tone (-)
-x:grape-like clusters
*Cause bleeding per trimester
1st – abortion
-ectopic preg. sharp stubbing unilateral pain
2 – H. mole – DOC –methotrexate
nd
-incompetent cervix – painless

rd
3 previa painless
-abruptio- sharp – colic pain /boardlike abd
-DM risk, HTN, cocaine use
*pt. shoulder dystocia – flex knees to abd to widen pelvic
outlet

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NCLEX- RN

REVIEW NOTES 2018

Few Tips and Mnemonics Included

Neurology & Sensory Disorders

Psychiatric & Mental Health Nursing

Maternal & Child Nursing

NEVER EVER DISCLOSE THIS TO ANY

CONSIDER THIS AS YOUR OWN

You may share it to your friend or anybody

Let us protect the one who compile this for

KNOWLEDGE IS ALWAYS FREE

Unfortunately, some of us can’t pay for the

May this will help you.

I'd really hope I will be able to help you reach your

Do your best, God will do the rest! The strongest

“Whatever you do, work at it with all your heart, as

2 Timothy 4:7. I have fought the good fight, I have

1. Fluids and Electrolytes Tonic – concentration of solution Tonicity

Pressure (artery) Albumin (IV)

• HCT - concentrated HCT Mgt: Demeclocycline (Declomycin)

2. Fluid Volume Excess (FVE) ➢ HYPERNATREMIA

ELECTROLYTE IMBALANCE H2O

1. SODIUM (Na+) – N 135 – 145 mEq/L S/Sx FVE

• GIT – constipation • opposite with impulses

(?1st) clamp MRSA (Methicillin resistant

DECUBITUS/PRESSURE ULCER MEDICATIONS AND CALCULATIONS

b. PNS (parasympathetic nervous system)

Otorrhea- CSF leakage in the ear Aphasia

Meds: Bromocriptine (Parlodel)-adenoma Thyroid hormone (1° hormone)

Kidney cannot concentrate urine

weight loss, polydipsia Dehydration

SNS hyperactive TYPE 11

PORTAL HYPERTENSION Cross blood brain barrier

Malabsorption of Fats, CHO, CHON

Cause: dropped fecalith, seeds Both- prone to DHN

Report: =. Brain = Cerebral edema - LOC

Anatomy & Physiology Breathing Nervous System Control

ZONE SYMPTOMS MGT

Magnetic Resonance Imaging – Use of strong magnetic

Affect weight bearing joints

Up with the Good

Thrombopoiesis - process of platelets formation

Conduction System of the heart

The Chest limbs

V1- 4th ICS R sternal border

NOTE: if you cannot identify the P waves automatic NOT

Sinus rhythms 1. Atrial flutter –saw tooth

3. Ventricular Fibrillation – no pulse / no

Ventricular rhythms – SA node & AV node fail!

4. Asystole – Mgt: CPR + intubate

Artificial Pacemaker Holter Monitor

Disorders in the heart

Pericardium – something to do with the pericardial fluid

II. Abdominal Aortic Aneurysm

Mania Points to remember:

Reflexes – disappearing age – any delays cause neurologic

4. Mongolian spots – bluish black pigmentation on

Hinduism- belief-reincarnation Mailine Protestant – No tobacco and alcohol

Renal Cancer INTEGUMENTARY

Plaque – group of papule &

Maternal and Child Nursing

G.I. function (dec) risk for constipation

- NO make-up, oil, lotion, cream applied breast