Le NotMyNotes: NCLEX

Delegation RN LPN SpecializedCare(Inc.Levelofskill,Newlyrecovered) RoutineCare SevereCases Chroniccases SterileProcedure Stableclients NewlyDiagnosed Unstableclients WithComplications(acute,lifethreatening) Assessment,Teaching,Evaluation UAP/NC ActivitiesofDailyLiving

o LatexAllergy=Kiwifruitallergy o HistoryofMVA(headtrauma)PolyuriaDiabetesInsipidus o Cushingstriad:1.)widepulsepressure 2.)Dec.RR 3.)Dec.PR *Noteadec.inLOCbeforeCushingstriad o SawPalmetto=SameasFinasteridepreventsdysuriagiventoclientswithBPHtodec.thesizeof prostate. o MaHuang=SameasephedrasubstituteofSudafedShabuoramphetaminelikeeffect o DiHuang=Dec.bloodsugarforDM o BlackCohosh=Inc.Estrogenformenopauserelieveshotflushes o BlueCohosh=auterinetonicforstartinglaboralsoafterdeliveryforuterinecontraction o Chamomile=CIinasthmacausesbronchospasm =CIwithgingkobiloba o HeartBlock=AtropineSulfate o Tachycardia=Lidocaine o Howmanyservingsofmilk,fruitandvegetablesaday=34/meal ChemotherapeuticAgents 1. Cisplastin=causesstomatitis 2. Azathioprine= 3. Methotrexate=Psychotropicprecautions ConversionDisturbances PrimaryGain MotivationBehindthes/sx SecondaryGain Theattentionthattheyget TertiaryGain Extenttow/cthes/sxis manifestedinordertoplease thehealthcareprovider

o GoalonPreeclampsia=Topreventseizure o IleostomyNormal23daysafter()discharge Fatembolism 1.) Dyspnea 2.) Chestpain 3.) Petechiaeonthechest o PriorityadministerO2Todec.surfacetensionoffatglobules DIC=DisseminatedIntravascularCoagulation o Systemicclottingbleeding o Priority=Preventsystemicclotting o NormalFibrinogenlevel=180340mg/dl <100bleeding

NarcoticWithdrawalSyndrome Hypertonicity Hyperactivity Irritability PoorSucking Sleepiness Shrillcry Highpitchedcry

FetalAlcoholSyndrome Hypotonicity Irritability PoorSucking FacialDeformity Microcephaly

o Priority=PhysiologicIntegrityVitalssignsGiveValium MacularDegeneration o CMV=Cytomegalovirusinfection o Lossofcentral&peripheralvisionblindness ErbsPalsy o Attainedduringdeliveryreversiblecompleterecoveryafter3months StepsofHeimlichManeuver =standbehind =wraparmsaroundtheclient =fistoverxiphoidprocess =upwardabdominalthrust SepticShock o Systemicinfection o Centralizedvasodilation o Dec.BP o Inc.Temperature CleftPalate o Postsurgery=prone o Postfeeding=sidelying CleftLip&Palate o Postsurgery=sidelying st o Cleftlipis1 donefollowedbytherepairofthepalate o Mustfirstsatisfytheruleof10: 1.) 10weeks 2.) 10lbs. 3.) 10Hgb Situationinwhichconsentofparentsarenotneeded: 1.) STDs 2.) Delivery 3.) Substanceabuse DiabeticClients o 5070%CHO o Raisinbesttobringduringtravel o 1riceisequalto2servingsofpopcorn

MI SequenceofenzymesthatincreasesduringMI: 1.) 2.) 3.) 4.) 5.) Myoglobin=30min1hrpostMI Troponin=36hrsupto3weeks CKMB=Inc48hrspostMI,backtonormalin34days AST=820u/Lnormal,Inc610hrspostMI,backtonormalaweeklater LDH=Inc23dayspostMI,backtonormalby1014days

LDH=4590u/mlNormal LDH1=Heart LDH2=RES LDH3=Lungs LDH4=Kidney&Pancreas LDH5=Liver PilocarpinesweatTest(InduceSweating)CysticFibrosis(Autosomalrecessive) DysthemiaLesssevereformofdepression IncentiveSpirometerInhale PeakFlowmeterBlowashardasfastaspossible GentamycinToxicEffects: 1.) Ototoxic 2.) Nephrotoxic 3.) Neurotoxic Influenzaevaccine VarivaxDonotgiveAspirinmayleadtoReyesSyndrome Kwell CItoptwithseizure DxProcedures: 1.) 2.) 3.) 4.) 5.) ABG Amniocentesis Thoracocentesis Bronchoscopy MRI

Angiogram: 1.) CapillaryRefilltime 2.) DistalPulses 3.) Puncturesiteforbleeding =IfthesiteisonthefemoralKeeplegextendedfor24hrs. RespiratoryAlkalosisbreathtoapaperbag RespiratoryAcidosisDeepBreathing Commonlyaskeddrugs: 1.) Lanoxin 2.) Heparin

3.) 4.) 5.) 6.) 7.)

Acetaminophen MgSO4 Cytoxan Synthroid Vaccines

DotheCHECKmethod Theophylloine=1020mg/dladult =510mg/dlpedia AcetaminophenSE=Hardstools Commonlyaskeddiseases: 1.) Alzeihmenrs 2.) SickleCellAnemia 3.) Pancreatitis 4.) BipolarDisorders 5.) LiverCirrhosis 6.) Hemophilia 7.) AIDS 8.) DM 9.) CysticFibrosis Droplet within3feet AirborneBeyond3feet Informedconsent o Foradultorminorwithcapacity o Requirefullunderstandingofprocedure o Protectstheclient,nurse,surgeonandhospital o Foremancipatedminors: o Marriedminors o Militaryservice o Livingawayfromhome o Hadachild Proceduresrequiringconsent: 1. SurgicalProcedure 2. Invasivethatrequiresentrytoabodycavity 3. Visualizationorradiologicprocedurewithcontrastmedium 4. GeneralAnaesthesia,localinfiltrationandregionalblock Conditionsthatdoesntneedparentsconsent: 15y/o=antibioticsforacne 16y/o=pelvicexam 17y/o=requestforcontraceptives 18y/o=DxexamforrecurrentH/A 19y/o=surgeryforbonetumor Assesment o Empoweringchildrentothegreatestextentfeasible ELEMENTS o Explaintothechildhisconditionandthereasonwhytheprocedurehastobedoneinlaymansterm o Clinicalassessmentofpatientsunderstanding o Solicitchildswillingness o Expectation EthicalCareConcept 1.)Autonomy=Livingwill,freedomofchoice,selfdeterminationandprivacy.

a. AdvanceDirective=Listofdonts(clientswithprogressivechronicillnessinwhichdeathisexpected) b. DurablePowerofAttorneyforhealthCare=appointsaproxythatwilldecideforthepatient. 2.)Beneficence=dutytopromotewellbeingofothers IdealBeneficence=Nagkusa 3.)NonMaleficence=Restrainedselffromdoingsomethingthatmightharmsomeone.Donotharm. 4.)Justice=Fairness ClinicalIssues 1.Unsafenurse/ptratio Intervention: o Addressverballyanddocument. o ReporttochargenurseSupervisordirector 2.NoresponsebyPhysician PromoteSafety: o Siderailsup o Moveptnearnursesstation o Userestraintsappropriately(lastresort) 3.Inappropriateorder o Documentit o Notifythechargenurse o Notifythephysician LegalIssues Malpractice=Negligentconductinrenderingprof.service =didnotexercisecare RespondeatSuperior=Superiorisresponsibletotheactionsofsubordinates. ReferralAgenciesforspecialcareduringadmission Ptadvocate=Empowerpttoknowhis/herrightsandprivileges 1.) 2.) 3.) 4.) socialworker Childrensprotectiveservices Adultprotectiveservices Organizations

Careofthehospitalizedclients MantouxTest 15mm=gen.population 10mm=DM,Alcoholism 5mm=HIV Areaswherebruisesareindicativeofchildabuse: 1. LowerBack 2. UpperBack 3. Sideoftheabdomen SpecialConsiderations Infants

o Greatestriskforfluidandelectrolyteimbalance o Hypothermiaandinfections o Approachtheminnonthreateningmanner

Toddler o Increasedseparationanxiety o Brieflypreparethemforproceduresduetoshortattentionspan o Describesensationthattheymayfeelduringprocedure Preschooler o o o o o Fearofphysicalharm Believethatillnessesisaformofpunishment Explanationsmustbebrief,honestandinnaturalterms Usedemonstrationsandplayinprovidinghealthteaching Canuseadultseatbeltif40lbsor40inchestall,alsoifhecouldlookatthewindowinsittingposition

SchoolAge o Realisticunderstandingofdeath=910 o Needsmoredetailedteachings o Allowthemtomakesomechoices Adolescence o o o o o Developedabstractthinkingandabilitytoproblemsolve Logicandreasoning Fullandhonestexplanation Primaryconcernarewiththepresenttime Focusonappearance

Elderly o o o o o o Nutritionisaprimaryconcern Muscleatrophy Decbodywater,BMR Decrenal,CV,GITfunction Dectaste,smell, visualacuity(cataract,arcucsenilis=fattydepositsaroundpupil_) WithmultiplemedicationsduetochronicdiseasesOH,Nephrotoxic

Triage=asystemofclientevaluationtoestablishpriorities PRINCIPLES EmergencySituation=greatestriskreceivespriority MajorDisasters=thoserequiringminimalcarearetreatedfirst =Thoserequiringspecializedcaremaybegivenminimalcareornocare

TreeofStrategyforPrioritizing Ask Look SameArea =allOB =allPsycho =allMS =allPedia Evaluateandlookfor =Complications =Immediateneed =Adverseeffects PrioritizingSignsandsymptoms Consider =SymptomsrelatedtoABC =symptomswhichareindicativeofcomplications PrioritizingNursingDiagnosis Consider =TyoeofN.Dx =Actual(Problem) =Risk(Vulnerable) =Possible(Inadequatedata) =Wellness PrioritizingInterventions DiagnosticVerifytheDxAssessment TherapeuticAssesspt TeachingInformingthepatient ReferralInvolvesamemberofthehealthteam IndependentDecisionMaking Levelsofprioritizing Level1:Emergent S=evereshcock C=ardiacarrest,CervicalSpineInjury A=irwaycompromise,alteredLOC M=ultisystem Where DisasterArea=Leastinjured EmergencyArea=Mostinjured Case VariousAreas Physiologicvs.Psychological Acutevs.Chronis Unstablevs.Stable

E=clampsia Level2:Urgent(stable) Fe=ver Mi=norburnless10% Mi=normusculoSkeletald/o La=creation Di=zziness Level3:Chronic/MinorInjuries Dentalproblems RoutineMedications MissedMenses ChronicLowBackPain Prioritize Cardiovascular=NeurologicalCases AcuteComplications Consider=AgeandDxofthept FortMSCases:ThinkABC ForPsyche:SafetyFirst Incaseoffire:ARCE(new) :RACEIfcausedbyO2,turnoffO2first DELEGATION:Transferofresponsibilityfortheperformanceofanactivityfromoneindividualtoanother. Direct:IdentifiedbytheRN Indirect:Taskbasedonthefamilieslist Complextask=neverdelegated =requiresjudgmentonhowtoproceed Noncomplextask:canbesafelyperformedrecordingtoexactdirections :canbedelegated Taskthatcannotbedelegated(HOSPITAL) 1.Administrationof: =Investigationaldrugs =CancerDrugs =IVpushdrugs =Bloodandbloodproducts =TPN =Implanteddevice 2.HemodialysisFunctions Taskthatcannotbedelegated(HOMEHEALTH) a.)initialsetupofptcontrolledanalgesicpump =changingofflowrates =changingmedicationsreservoir =fillingthereservoir b.)NGTfeeding KNOWTHERULES 1.)Donotdelegate:

o o o o

Assessment Teaching Evaluation Preparationandadministrationofmeds

2.)Delegate o ADL o Routine o StandardProcedures Knowthe5rightsofdelegation 1.)RightTask 2.)RightCircumstances 3.)RightPerson 4.)RightPerson/Communication 5.)RightSupervision Social Relationship Goals:Socialization Goal:MentalHealth trust Phases: 1. Preinteractionselfawarenessofnurses 2. Orientationcontractdosanddonts 3. Workingphaseidentification&resolutionofproblems 4. Terminationphaseevaluation TherapeuticCommunication 1. 2. 3. 4. 5. Dontaskwhy Avoidpassingthebuck Dontgivefalsereassurance Avoidnursecenteredresponse Recognizetheptsfeelings Therapeutic

CORECONCEPTS o o o o o Therapeuticphrases Openendedquestionsare GenerallyTherapeutic Closedendedeffectiveformanicandptsincrisis Directquestionsforsuicidalpts

Bruit=highpitched Murmur=lowpitched 20/20=Visionattainedat36yearsold Decorticate Flexed Adducted Plantar Flexed Extended Arms Legs Decerebrate Flexed Abducted Plantar Flexed Extended

Howtoattackthequestions? 1. 2. 3. 4. Considertheptsdx Knowwhatisnormal Someconditionshaveinherentandexpectedchangesinthenormalvalues Minimaldeviationfromnormalvaluesarenotreportable

Sodium=135145Meq/L DilutionalHyponatremia=<120Increiskforseizure =115SeizurePrecaution AddisonHyponatremia,Hyperkalemia CushingsHypernatremia,Hypokalemia Potassium=3.54.5Meq/LNormal =<3.5Muscleweakness Calcium=4.55.5Meq/LNormal =910mg/dl HypercalcemiaIncH2Ointake MultipleMyelomaIncserumcalciumlevel HypoparathyroidDecCa Levelsinblood ThyrocalcitoninDepositsCatobones ParathyroidHormoneBoneCatoblood Glucose =<50Hypoglycemia =>140Hyperglycemia CREATININE=.51.5Meq/L =Bestindicatorforkidneyfunction =InccreatinineKidneyfailure BUN=1020mg/dl =Alsoanindicatorforkidneyfunction =IncBUNKidneyfailure RBC=4.55.5 =Decbleeding,shock,anemia =Incinpolycythemia =Phlebotomyremovalof500mlofblood =DecRBCActivityintolerance =IncRBCCVARiskforinjury WBC=5,00010,000 =Postpartum>15,000 =Leukemia>150,000HyperleukocytosisRiskforinjury Platelets=150,000450,000 =<150,000Thrombocytepenicprecaution =<20,000bleedingprecaution =>500,000bleedingd/o =RiskforInjury PT=1112seconds INR=24seconds =>24bleeding X20

10

PTT=6070seconds INR=175seconds APTT=3040seconds INR=100seconds MonitoredHeparin =>INRbleeding

X25 X25

Hbg Female=1216 Male=1418 Newborn=1424 Pregnant =1012 =<10report =ResultstoAnemiaActivityIntolerance Hematocrit=3545 Dangerofhydration =<35OverhydrationFluidVolumeexcess =>45UnderhydrationFluidVolumedeficit

AcidBaseImbalance Respiratory Alkalosis DefinCO2 Hyperventilation Hypermetabolism Hypoxia Hypotension s/sx Restlessness Anxiety Tachycardia Syncope Acidosis ExcessCO2 LungDisease Airwayobstruction RespDepression Neurological&Musculardse s/sx Restlessness Apprehension Tachycardia DecLOC DecDTR Alkalosis ExcessHCO3 Cushings Hypokalemia Excessivelossofacids GIvomiting s/sx Cyanosis Hypotension Apathy Weakness Metabolic Acidosis DefHCO3 Ketoneoverload LacticAcidproduction KidneyDisease GIdisease s/sx Confusion Hyponatremia Anorexia Weakness DullH/A Kaussmaulsbreathing Mechanicalventilator

Breaththrupaperbag Breaththrucuppedhand

Deepbreathing

AdministerAmmoniumCl ABGdetermination Alkalosis

Acidosis Dec Dec Inc

PH7.357.45 Hco32226 CO23545

Inc Inc Dec

11

HCO3determinantforMetabolicd/o CO2determinantforrespiratoryd/o RAMS=Respiratoryd/o,Alternatearrowdirection =Metabolicd/o,Samearrowdirection Compensation Compensation Uncompensated Partially compensates Fully compensated PH Abnormal Abnormal Normal Compensatory Mechanism NoChange Change Change

APGAR 1minteAssesscardio,pulmonaryandneurologicalstatusofthebaby 5minutesadjustmenttoextrauterinelife nd 10minuteswhen2 apgarisbelow6 710admission 46O2andwarm 03Resuscitation 0 Allblue Absent Norxn Flaccid Abnormal 1 Acrocyanosis <100 Weakcry Someflexionandextension Irregular 2 Pink >100 Vigorouscry Spontaneousflexion& extension Lusty

Appearance Pulse Grimace Activity Respiratoryeffort

Computation: 1.) 2.) D S Vol.inccXgttfactor #ofhrs.X60

3.)IVfluidreplacementinpediatricpt Weight <10kg X100/kg 1120kg 1000ml/10kg InexcessX50 2kgs 1,500ml/20kg inexcessX20 IsolationPrecaution HW PR X Mask,goggles (surgical) Gloves Gown

I.Standard II.Transmission Based a.Doplet b.Airborne

(PRM)

X X

X X

12

c.Contact

PRM(particulateRespiratorMask)

I. StandardAiDS,HIV,Hepa,Roseola II. TransmissionBased: A. DropletMumps,MycoplasmalPneumonia,Rubella B. AirborneMeasles(Rubeola),TB,Varicella C. ContactClostridiumdeficile,Respiratoryborne,scabies,Sarcoidosis,RSV HepawithbowelincontinenceContactprecaution Principles: 1. Ifpatientgoesoutfromtheroomletthepatientwearmask 2. CohertingSameillnessShareroom 3. StandardPrecautionexemptioninpediadiapered,incontinent,<6y/ocontactprecaution HERBALREMEDIES SawPalmetto o StopsprogressionofBPHlikeFinasteride o Easeurinarydifficulty o Interfereswithironabsorption o CI:pregnancyandlactation o SE:stomachache BlueCohosh o Uterinetonic o Usedinthelast24weeks o Toeaselaborpains o Jumpstartstalledlabor o Deliverretainedplacenta o Stopbleedingafterdelivery BlackCohosh o SppressLHbutnotFSH o Relievessymptomsofmenopause o Nothabitforming o Doesnotcausecancer o Limituseto6monthsaltersthenormalhormonalbalance MaHuang o CNSStimulant o Causesaddiction o Withdrawalsymptoms:depression,fatigue,irritability o Withephedralikeeffect o Usedtotreatasthma o Cancauseweightloss o NotgiveninpatientswithDMaltersthebloodsugarlevel Chamomile o Fordiarrhea,antibacterial,antiviral o CI:Bronchialasthma,anticoagulanttherapy Cranberry o ForUTIandasthma o NotforDM o Safeinpregnancy o UsewithcautioninDM Echinacea o Immunesystemstimulant

13

o Notusedformorethan14days o Storeitawayfromdirectlight o NotgiveninTBandchronicconditions Ginger o Antiemetic,txforcolicandflatulence o ReportbleedingandCNSdepression Ginseng o Fatigue,atherosclerosis,depression,Ca o Reportginsengabusesyndrome,Diarrhea,nervousness,edema,insomnia GingkoBiloba o Improvesbloodcirculation o UsedinAlzheimersDisease o CIpregnancy,lactationandclottingd/o GotuKova o Improvesmemory o ForUTI,snakebites,rheumatism o CI:pregnancy,lactationanduseofsedatives KAVA o Anxiety,menstrualproblem,leprosy o AE:CNSdepression,hepatotoxicity o Notgiventoptswithantipsychoticincsedativeeffectsofdrugs VALERIAN o Tranquilizer,sedative o Notgivenwithvalium o Uses:insomnia,mm.spasm DRUGS IronSupplements FeSO4 C=MineralSupplementAnemia H=Reliefoffatigue/Incstrength E=Bestbeforemeals,aftermealsifwithGIirritation C=takeseffectafter23weeks,Incabsorptionwithorangejuice K= Elixiformusestraw InjectableZtrackmethod(laterallystretchtheskin,10seconds) SE:Constipationandblackstools Antidote:DeferoxamineHCL(Desferal) RHOGAM C=PreventsRHsensitization H=()Hemolyticreaction E=2728weeksAOG,ideally72hrsafterdeliveryofbabywithRh(+)and()Coombs C=Painininjectionsite K=CheckCoombstestonlyin() OXYTOCIN Pitocin C= InduceLabor Increaseforceof Uterinecontraction H=firmlycontracteduterus Methergine Contractsuterusafterplacentaldelivery

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E=Asprescribed C=Reportprolongeddurationofcontraction K=Avoid:Bluecohosh CheckBP o PitocininitiallycausesHypotensionthenreboundhypertension o MethergineinitiallycausesHypertensionthenreboundHypotension

TOCOLYTICS C=Relaxestheuterinemm.duringpretermlabor H=()contractions/relaxeduterus RitodrineHCl(Yutopar) E=Onsetofpretermlabor C=Reportmaternaltachycardia HR>130Arrhythmia K=PrepareantidotePropanolol MagnesiumSulfate C=Anticonvulsant,NSdepressant H=()Seizure E=AsprescribedPIH C=ReportMgSO4intoxicationHypotension,hypocalcemiaandH/A K=CheckBP,urineoutput,RR,Patellarreflex ifDecantidoteCaGluconate Therapeuticlevel: o Loadingdose47Meq/L o Maintenance 1.53Meq/L o DepressionofDTRif8Meq/L o DecRRif1012Meq/L CoagulationProcess VitKdependentclottingFactors Thromboplastin Prothrombin Coumadin Coumadin/Heparin Coumadin (Oral) C= H= E= C= K= Heparin (Injectable) Heparin FibrinogenFibrin(clot) Thrombin

Anticoagulant ()Clotformation Onset:25days 12days Reportsignsofbleeding AvoidgreenleafyVegetable(containsVitK)

15

Avoidhardbristletoothbrush Antidote: Lab: VitK PT ProtamineSulfate PTT

CHEMOTHERAPY CELLCYCLE G0 Interphase Resting G1 S G2 RNAsynthesis PlantAlkaloid InterferesDNA synthesis *ONCOVIN Hormones InterferesRNA synthesis *TAMOXIFEN Celldivision Mitosis

RNAproductionDNAsynthesis AlkalatingAgents InterferesDNA replication *CYTOXAN *MUSTARGEN Antimetabolites InterferesDNA& RNAReplication Antibiotic InhibitDNA& RNAsynthesis

*METHOTREXATE *ADRIAMYCIN (antidote:Leucoverin) GLENOXANE

C= Typical

ANTIPSYCHOTIC Atypical Antiemetic Mania Schizophrenia Bipolard/o Haloperidol(Haldol) Dec(+)symptoms (walasanormalbeing) Clozapine(Clozaril) Dec(+)and()symptoms Apathy Alogia Avolition Anhidonia Decdopaminelevels

H=

Hallucinations Delusion LoosenessofAssociation

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E= C= Sideeffects: 1.)Agranulocytosis Fever,sorethroat 2.)NMS Fever,mmrigidity 3.)EPS Mmrigidity EPS=Cogentin Akineton Artane MalignantHyperthermia=Parlodel Musclerigidity=Dantrolene,Dantrium K=

pc=aftermeals Anticholinergic Tachycardia Drymouth BlurredVision Constipation DecBP SideEffects: Leukopenia(<3,500=signsofinfxn) (if<2,00=protectiveisolation)

LiverFxnTest Nodirectexposuretosunlight=Photosensitivity AntiParkinsonianathand CI=St.Johnswort ANTIPARKINSONIANAGENT Dopaminergic IncDopamine LDopa Carbidopa (Sinimet) Anticholinergic DecAch Congentin Benadryl Decmmrigidity Decpillrolling (after23weeks) aftermeals H/A,Irritability,Restlessness NotoVitB6=decabsorptionofdrug CheckBPandHR NoCHON ANTIANXIETY Valium Librium=Acutealcoholwithdrawalsyndrome =dectremors

C=

H= E= C= K= C=

H= E= C=

Deccenterofwakefulness Beforemeals Dizziness Drowsiness DryMouth AvoidAlcoholandCaffeine AdministerValiumseparately=incompatiblewithanyotherdrugs AvoidKAVA&VALERIAN=IncRespdepression

K=

17

C= SSRI TCA

ANTIDEPRESSANT MAOI Stimulant

ZOLOFT

VIVACTIL CETAVIL TOFRANIL Preventsreabsorption ofNorepinephrine Aftermeals

PARNATE NARDIL MARPLAN Preventsthedestruction ofserotonin& Norepinephrine

RITALIN

H=

Decreuptakeof Serotonin

Directlystimulates theCNS

E= C=

Incappetite Adequatesleep Initialeffect=23weeks Fulleffect=34weeks Sideeffects: Declibido Impotence CardiacArrhythmias HypertensiveCrisis Growthsuppression

K=

ChecktheBP AvoidCitrusjuicesDecabsorptionofantidepressants Observedietarymodifications AvoidSt.JohnWort AvoidTyraminecontainingfoods: Cheddar,Swiss,CottageandAgedcheese Cola,coffee,soysauce ANTIMANICAGENTS LITHIUM TEGRETOL DEPAKENE (Carbamazipine) (ValproicAcid) AntiConvulsant Alternativedrugforpregnant Women DecHyperactivitywithin23weeks AcuteMania=GiveAntiPsychoticwithantimanic Aftermealspc Mild 1.5Meq/L Thirst Ataxia H/A Irritability BeginningFinehandtremors Checksignsoftoxicity: Moderate 2.5Meq/L Nausea Anorexia Vomiting Diarrhea Coarsehandtremors AbdominalCramps ComaDeath Severe >2.5Meq/L

C=

H= E= C=

K=

MonitorLithiumLevelearlymorning(beforebreakfast) Outpatientatleastonceamonth

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DrugofchoicefortoxicityDiamox,Mannitol CI: 1.) Pregnancy 2.) Lactation 3.) RenalFailure DietaryModificationIncNa(610gm)andIncFluid(3Lormore) AcuteDose:.51.5Meq/L Maintenance:.51.2Meq/L Elderly:notexceed1.0Meq/Lduetopoorrenalexcretion

MUSCULOSKELETALDRUGS

C= H= E= C=

Focus:GoldTherapy SuppressesArthritis ()Inflammation IMweekly Liesupinefor10minstopreventOH Check: SignsofStomatitis Dermatitis UnusualBleeding UnusualBruising Fever SoreThroat MonitorRenalFunctionTest ANTIINFLAMMATORY Ibuprofen (NSAIDs) Aspirin

K= C=

AntiInflammatory Antipyretic Analgesic ForRA&OA H= E= C= Report: ()Inflammation,()pain,()RA ()fever,()plateletaggregation pcaftermeals

AntiInflammatory Antipyretic Analgesic AntiPlateletaggregate Antirheumatic

19

Visualdisturbances Allergy Sorethroat Fever BlackStool K= Annualeyeexam Checkbleedingtime ANTIGOUTAGENTS Probenecid Colchicine Acute (812hrs) Preventdepositionofu.a. Antiinflammatory Decreaseuricacid Givenwithfood NAVDA Allergy Bruising

Ringingintheears Nausea&Vomiting Rapidbreathing Hyperpneatoxicity

C=

Allopurinol Chronic (13weeks) Preventformationofu.a.

Excretionofu.a. H= E= C= K=

H/A,drowsiness Agranulocytosis

Incfluidintake23L/day Frequentlycheckserumuricacidlevel CARDIACDRUGS

NITRATE A.Nitroglycerine Sublingual Transmucosal=betweengums,cheecksandlips B.Isordil Sustainedrelease,withwateranddontcrush Patch NasalSpray C= Caridacdrug(Nitrate) DilatecoronaryarteriesandarteriolesDecpreload H= E= C= ()AnginalPain Givebeforeonsetofpain 3Xat5minsinterval After15mins(+)painreportMayindicateMI 1.Ointment=Coverwithplasticandputadhesivetape 2.Patch=NonHairypart 3.Oralspray=3spraysin15mins S.E.Facialflushing,H/A,Hypotension K= RiseslowlytopreventOH Tabletondry,darkcontainer 6monthsDiscard

20

BurningSensationIndicationthatthedrugisstillpotent C= Digoxin H= CARDIACGLYCOSIDE Digitoxin StrengthenMyocardialContraction NaKpumpisconvertedtoNaCapump Thusincreasingforceofcontraction Onset520mins ObserveGIirritation C= Excretedbykidneys Normallevel1426 K= CheckHR=Adult60 OlderChildren=70 Infants=90110 Excretedbytheliver Antidote:Digibive Normallevel52ug/dl Onste30mins2hrs

E=

DOPAMINEandDOBUTAMINE DOPAMINE Incforceofcontraction CorrectHemodynamic ForEmergencySituation H=AdequateUrineOutput E=EmergencySituation C=Alwaysindilutedform K=Computethedrugsproperly DOBUTAMINE

C= Lidocaine (Xylocaine) ForPVCs H=

ANTIARRYTHMICS Quinidine AtrialFibrillation ()Arrythmia Slowventricularrate Slowatrialrate

E=Givenasprescribed C= Rash Convulsion BlurringofVision Tinnitus/Ototoxicity

K=CheckHR EvaluateECG

21

C=

THROMBOLYTICS Streptokines TPA Dissolvestheclotbypreventingtheformationoffibrin(fibrinolysis) ()Clotformation ClotDissolved Effectivewithin6hours AfterMIwithin24hrs Report Bleeding MonitorVS Contraindicatedtoclientsthatarepronetobleeding

H= E= C= K=

C= LOVASTATIN (Tablet) H= E= C= K= Beforemealsoratnighttime Caution:Hepatotoxic

ANTILIPEMICAGENTS QUESTRAN (Powder) DecLDL=3080 (HDLshouldbe>80andLDL<80)

Questran1packofpowder+46ozoffluid(water,milkorjuice) Checkliverfunctiontest Rashandbleeding PERIPHERALVASODILATOR Paracid SmoothmusclerelaxantFacilitatesbloodcirculation

C=

H= E= C= K= C= H= E= C= K= C=

()Ischemia AfterMeals InstructpatientthatdrugmaycauseH/AandSOB Longtermuseisindividual BETABLOCKER (Timolol,Esmolol,Nadolol) DecBP,forHyperthyroidism,Decsympathetic(Autonomic)nervoussystemstimulation Beforemeals Riseslowly:Liedownfor30minsaftermedication. Instructpatientthatmedsmaycausebronchospasm Donotgivechamomileandaspirin ANTICHOLINERGIC

22

AtropineSulfate VasolyticAgent H= E= C= K= Incheartrate(checkcompleteheartrate) Beforemeals Avoidhotenvironments CheckforrashesandSOB NEURODRUGS Anticonvulsants (Dilantin) DecreaseSeizureThreshold AfterMeals EpilepsyMaintenance ChronisUseGingivitis Visitdentistatleastonceayear Softbristletoothbrush,massagethegums Urineispinktinged SAS(SalineFlushAdministerdrugSalineFlush ToPreventprecipitate CHOLINESTERASE Neostigmine MyastheniaGravis LongActing Treatment H= E= C= ShortActing Diagnostic Incmusclestrength BeforeActivity BeforemealsUsemusclesofmastication Chewingbecomesstronger Medicationislifetime ReportS/Sxofhepatotoxicity Checkliverfxntest KeepatbedsideNeostigmineAntidote:atropinesulfate Donotgiveechinicea PrepareTracheostomy ANTITB Rifampicin H= ()Infection INH Streptomycin Ethambutol Tensilon Cognex Alzeihmers Maintenance Treatment Incmentalfunctioning Atbedtime Decdizziness

C= H= E= C=

K=

C=

K=

C=

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E= C= K=

BeforeMeals Redorangeurine Dontusecontactlenses PeripheralNeuritis (GiveB6) Oto,nephro,neuro TOXIC Hepatotoxic PsychoticlikeSx

Takethecompletetreatmentasprescribedbythedoctor(612months) IncompleteTBtreatmentLeadtoMDRTB

C= Theophylline Adult=1020mg/dl Pedia=510mg/dl Dilatesbronchioles H= E= C= K= Easebreathing Inthemorningbecauseitcausesinsomnia Nauseaandvomiting Theophyllinetoxicity Checkthepulserate AvoidChamomilecausebronchospasm Avoidaspirin?Causebronchospasm InhalerAcute SteroidChronic

ANTIASTHMA CromolynNa Preventsantihistaminerelease

Rashes

C=

MUCOLYTICS (Mucomyst) Antidoteforaspirintoxicity Decviscosityofmucous Loosephlegm Nospecifictime IncOFI S.E.bronchospasm Suction Medicationhasafoulodorthatresemblerottenegg EMETIC SyrupofIpecac Toinducevomitingnoncorrosive Pediabelow6months()vomiting Dosedependsonage 6mos1yr=10ml 112yrs=15ml >12yrs=30ml Administerwithglassofwatertoenhanceeffectsofipecac Cardiotoxic=Ensurethatchildvomitstheentireamount

H=

E= C= K=

C=

H= E=

C=

24

C= Maalox 12hrs NeutralizesHCl

ANTACIDS PepticUlcerDisease Ranitidine 46wks DecHClsecretion NormalHCL25 Maximum10

Sucralfate 8wks CoatsGIT

H= E= C=

()Pain,decHCl Usuallyonanemptystomach 1hourbeforemeals 2hoursaftermeals Shakeliquid SE:diarrhea Constipation ShorttermtherapyElectrolyteimbalance

K=

ENDOCRINEDISEASE C= INSULIN Type1 RegularHumulin IntermediateNPH Longactingultralente H= E= C= Inctransferofglucosetocellmembrane Beforebreakfast ReportHypoglycemia: Dizziness DecLOC Diff.ofproblemsolving Hypooccursusuallyoccursatthepeakofactionofmeds: Beforelunch Intheafternoonorbeforedinner Inmidnightornextday Rank:4812/16 DiabetesMellitus OHA Type2 Orinase Diabinase Metformin Pancreastosecreteinsulin

K=

C= Synthroid (supplement) ForHypothyroidism H= NormalBMR

THYROIDDRUGS PTU Tapazole(10timesgreaterthanPTU) ForHyperthyroidism DecT3andT4,Adequateappetiteandsleep

25

E= C= K=

Inmorningtopreventinsomnia Reportsignsofoverdose: Insomnia,palpitation&Nervousness Lifetime

Roundtheclock Report: Fever,sorethroat,bodymalaise MonitorHR&BP

C= Cortisone

STEROID Floricef ReplacementTherapy AddisionsDisease

H= E= C=

CorrectFluidandelectrolyteImbalance Inthemorning Givenintramuscularly Avoidabruptwithdrawal AE:BruisingBonemarrowdepression Avoidsaltyfoodsedema Maintainabalancedietobesity AvoidcrowdedareasInfection RENALDRUGS EPOGEN IncRBCproduction forChronicRenalFailure NormalHemoglobin Asprescribed ReportPolycythemiaIncproductionofRBCCVA CheckCompleteBloodCount DIURETIC ThiazideDiuretic (Hydrochlorothiazide) Duiril DistalTubule PreventsNaabsorption Increaseurineoutputanddecreaseptsweight Earlymorningpreventnocturia Hypokalemia DecK Decna Hypokalemia DecK DecNa DecCa Decmg IncSodiumindiet CheckElectrolytelevel CheckBP IncK DecNa

K=

C=

H= E= C=

C= LoopDiuretic (Lasix)

KSparringDiuretic (Spirinolactone) Aldactone Blocksaldosterone Retainswater

LoopofHenle PreventNaabsorption H= E= C=

K=

26

IMMUNUREN (Azathioprine) C= H= E= C= Immunosuppressant ()rejectionoforgans Asprescribed Report: Nausea,vomiting Thrombocytopenia Bruising Infection CheckCBC FrequentHandwashing MIOTICS (Pilocarpine) ForGlaucoma NormalIOP Lifetimeinglaucoma Lowerconjunctivalsac Pressinnercanthus12minsto preventsystemicSE CheckBPandBloodsugar MYDRIATICS (ATSO4) CIforGlaucoma Foreyeexam Dilatationofpupils Asprescribed Report:eyepain&blurringofvision Avoidalertnessaftermedication

K=

C=

H= E= C=

K=

C= Vancomycin MRSA

ANTIBIOTICS Penicillin Gonorrhea Syphillis ()Infection Beforemeals WithGIirritationAftermeals Ototoxic,Nephrotoxic, Neurotoxic Allergy CheckIandO PeakLevel=1530minsafteradministration Troughlevel=1530minsbeforethenextdose Antidote:Epinephrine Givenwithprobenecid DeepIMandcheckCBC Hepatotoxic Tetracycline Lymes RockyMountainFever

H= E= C= K=

GuidelinesonGrossCulturalOrientationandadjustment

27

Trytogettoknowasmuchasyoucanabout: o Socialcustoms o FamilyLife o Classstructure o Religion o Economics o ValueSystem SomeAreasofCultureDifferences 1.Communication o Messageinterpretation o PersonalSpace o Eyecontact o Touch 2.ViewofTime o Presentoriented(Hispanics,Africans) o Futureoriented(Europeans,Americans) o PastOriented(Tribal/Traditional) 3.FamilyType o Nuclear o Extended 4.Nutrition=kosherdiet,jalal 5.Religion o Catholics o JehovasWitnesses th o 7 dayAdventist o Mormons CultureBoundSyndrome BlackIncblood ChineseKoro HispanicsPasmo WhitesAnorexia,Bullimia DeathandDying ASIANS Familyandfriendsofsamesexwillprepareandwashthebody MUSLIM 1. Washingofthebody womencleansewomen mencleansemen 2. Afterwashing3timethebodyiswrappedin3piecesofcleanwhitecloth 3. Specialprayers 4. Burythebodywiththeheadfacingmecca 5. Burialoffetus=<130daysdiscardliketissue =>130daysproperburialrites JEHOVASWITNESS o Autopsyisacceptedifrequiredbylaw o Thepartstoberemovedfromthebody o Cremationispermitted

28

FRAMEWORK MainProblem: SIADHNeuroendocrine Mostcommon/initialmanifestations=SIADH Oliguria LaboratoryData=DecNa,IncBP NursingDiagnosisDecNaN.Dx.FluidandElectrolyteimbalance PriorityIntervention=DecNa115meq/LImplementseizureprecaution Leukemia MainProblem: ProliferationofImmatureWBC Periodsofremissionandexacerbation Remission=Absenceofs/sxLymphycyticLymphocytesPedia Exacerbation=Actives/sxMyelogenousGranulocytesAdults S/SxInitial:Anemia Bleedingsevere/unexplained Infection Lab.Data: WBCHyperleukocytosis WBC150,000

N.Dx: PrioritySafety Reverse,Isolationprecautionrelativewearmask Thrombocytopenicprecaution CytotoxicPrecaution BleedingPrecaution StandardPrecaution HEMOPHILIA MainProblemInheriteddisorder TypeA Xlinked Recessive 50%maleoffspring ()Factor8 TypeB Xlinked recessive 50%maleoofspring ()factor9 VonWillebrandsdisease Autosomaldominant Male&Female

S/Sx: HemarthrosisHallmarkelbow,wrist,ankles,knees Hematoma Hematuria Hematemesis Hemmorhage LabData:Clottingtime N.Dx:Riskforinjury,alteredgrowth Priority:Safety BloodTransfusion,PlasmaExpanded 1. Rest 2. Immobilize 3. Coldcompress 4. Elevate

29

SICKLECELLANEMIA IRON DEFICIENCY ANEMIA PERNICIOUS ANEMIA FOLICACID DEFICIENCY SICKLECELL ANEMIA APLASTICOR FANCONIS ANEMIA THALASSEMIAS 1.Minor 2.Intermediate 3.Major Duetodefectinpolypeptidechains ofRBC

Inc.def.ofiron Decabsorption Excessiveloss

LackofVit.B12 Absenceof intrinsicfactor Instomach:

Deficiencyin FolicAcid

Inherited Autosomal Recessivestatusof Parents (SeeTableA.1below)

Pancytopenia Hemolytic

Babychubby butpale Duetooverintake ofmilk Women menstruation

Agingatrophy Surgery removal

S/Sx:3Fs: Fatigue,Fainting, Forgetfulness

S/Sx:3Fs+ beefyred Tongue (glossitis) Peripheral neuritis Lab:schillings test N.Dx.Riskfor injury Priority: Rest B12supplement *Absenceof beefyred tongue

Pregnant Breastfeeding Infant Adolescent Alcoholic Poorfeeding practice Overcookingof veggie S/Sx:3Fs Withperipheral neuritis

RBCC/Sshape thrombusoccludebv VasoclusiveCrisisduetoDHN AplasticCrisis(hemolyticanemia) decRBC,WBC&platelets Spleenicsequestrationcrisis spleendestroysrbcrapidly

DecRBC,wbcand platelet

RBCdestruction Commoninblacks,Indians,Greeks, Chinese&Italians

S/Sx:Fever,jointpain, paralysis&weakness CVA

S/Sx:3Fs,Inc infection,Inc bleeding

N.Dx: ActivityIntolerance Priority: Bedrest, supplementIron2 wks, Incirondiet organmeats, Greenleafy vegetables,dried fruits ReliefofFatigue *Desferral Antidote

Lab:FolicAcid <4mg/dl N.Dx:Fatigue Injury Priority:Rest FAsupplement GreenLeafy veg Spinach, broccoli HelpRBC production

Labdata: *Sickledextesttrait *HgbelectrophoresisConfirmsthe disease N.Dx:ActivityIntolerance,Riskfor injury,unilateralneglect Priority:Painrelief&hydration Bloodtransfusionreferto geneticists

LabData:DecHgb, wbc&platelet N.Dx:Riskforinjury, Infection,activity intolerance Priority:protectform infection,CBR,BT

S/Sx:Dependsintypes Mild:Mildanemia Intermediate:Anemia,spleeno megaly,hemosiderosis, accumulationofironintissues Major:severeanemiawith hepatomegaly LabData:DecHgb N.Dx:ActivityIntolerance Priority:Bedrest,steroids, spleenectomy

30

TableA.1:AutosomalRecessive Normal A.1parentwithtrait 50% B.2parentswithtrait 25% C.1parentwithtraitthe 0% Theotherwithdisease D.Bothparentswithdisease )%

Trait 50& 50% 50% 0%

Disease 0% 25% 50% 100%

NeoplasticThrombocytopenia PurpuraDecPlateletduetoviralinfectionautoimmunereactiondruguse S/sx:Petechiae,ecchymosis,hematoma LabData:Platelet<20,000,DecHgb N.DX:Riskforinjury Priority:Safety,preventbleeding Supplementwithfolicacid Bloodtransfusion CHD ACYANOTIC (Lefttorightshunting) Incpulmonarybloodflow Ventricularseptaldefect Atrialseptaldefect Patentductusarteriousus Obstructiveconditions Pulmonarystenosis Aorticstenosis Coarctationoftheaorta CYANOTIC (Righttoleftshunting) Decpulmonarybloodflow TetralogyofFallot Truncusarteriosus Transpositionofgreatvessels Tricuspidatresia Hypoplasticleftheartsyndrome

Riskfactors: Maternalinfection(14mos) Age(>40) MedicalCondition(DM) Alcoholism Browseating(feeding)duetoactivationofANS Babysleepsafter3minutesofsucking Difficultyinfeeding Tachycardia Tachypnea FrequentURTI HeartFailure RetardedGrowth SemiFowlers Priority:providewarmth Initial:Lsidedheartfailuredyspnea &O2&surgery Late:Rsidedheartfailure <2y/o=O2 27y/o=Surgery>7=Surgeryassoonaspossible Cyanotic(tetspell) CVA Ifwalkingsquat Ifnotwalkingkneechest

31

RHEUMATICFEVER Systemicinflammationofconnectivetissues(joints,CNS,heart) RiskFactors:(conditions24weeksbeforediagnosis) Sorethroat Impetigo ScarletFever S/Sx: Major: Carditistachycardiaatrest Arthritismigratory SubQnodulespainless EryythemaMarginatumrashes ChoreaAbnormalmovement Minor: Fever Murmur Tachycardia

Lab:IncESR=Male(12mm/hr,Female20mm/hr),IncASItiter N.Dx:Alteredtissueperfusion,DecCO,Pain Diet:Incfluidintake,IncCHON Meds:ASA,Penicillintopreventheartvalvulardamage Complications:CardiacValvularDiseasestenosisandregurgitation Stenosisnarrowing,fusionofleaflets Regurgitataionincompleteclosure STENOSIS Mitral Decpitch Diastolicmurmur Aortic Highpitch Systolicmurmur REGURGITATION Mitral Highpitch Systolicmurmur Aortic Blowingdiastolic murmur

Treatment: Antibiotics Anticoagulants PregnantClientsClassifications: I NoLimitationofactivities II Symptomswithactivities ofdailyliving III Symptomswithless thanordinaryADLs IV Symptomsevenat rest

ARRYTHMIAS =Abnormalcardiacrhythm ATRIAL Flutter Fibrillation PVC ExtraQRS Lidocaine Defibrillation VENTRICULAR Fibrillation WidenedQRS

SawtoothpatterPwaveP:QRSratio2:14:16:1 Quinidine Defibrillation Epinephrine Defibrillation

32

CPR CPR,Quinidine QRS=<.10,2squares PR=.12.20=35smallsquares ABNORMALCARDIACRHYTM HeartBlockPRinterval PrimaryprolongedPRInterval =Nointervention SecondaryProgressivelyprolongedPRInterval =AtropineSulfate TertiaryP&Rwaveareindependentofeachother =Pacemaker =HR<5beatsbelowthelimit =HiccupsFailure =Belchingdecreasingheartrate =Signsofshockweakpulse =Stayawayfromelectromagneticfield CAD o o o o Narrowingandobstructionofcoronaryarteries DecO2HypoxiaAngina ()O2Neurosis RiskFactors: CAD Atherosclerosis Smoking ElevatedCholesterol HPN Obesity Physicalinactivity Stress MI

CPR

Angina

StablePatternispredictable AnteriorWall UnstablePatternisunpredictable Variant(Printzmetal)Severeform PosteriorWall Nocturnal__>@night Decubituswhenlyingdown LateralWall IntractableUnresponsivetotreatment PostMIAfterMI Pain <20min Uppersternum Pressure Relievedbyrest Nitroglycerine Precipitates: Eating Elimination Extremetemp Emotion Effort AssociatedS/sx: Agitation Restlessness Coldclammyskin Pain >20min Lowersternum Crushing,Excruciating Notrelievedbyrest Morphine(CheckRR)AntidoteNaloxone

33

HPN

LabData: Inccholesterol<200 ECGchanges N.Dx:Pain PositioninSemiFowlers Administerdrugsasordered Diet: Cholesterolrestricteddiet PercutaneousTransluminalCardioAngioplasty

Inccardiacenzymes IncSTsegment IncESR

=Doneif50%ofbloodsupplytoheartisimpended =Insertionofaballoontippedcatheterballooningcardiacstent CoronaryArteryBypassGraft =Doneif50%ofbloodsupplytoheartisimpended =Placinganewbloodvessel HealthTeaching: o Avoidstrenuousactivities o Canresumesexualactivityifcanclimb23flights ofstairswithnodyspnea o Providefrequentrestperiods o DischargeInstructionsAvoidlifethreateningconditions HEARTFAILURE =Inabilityofthehearttopumpadequateamountofbloodtomeetthemetabolicdemandofthebody. RiskFactors: MI Heartvalvulardisease RHD HPN Arrhythmia S/Sx: Leftsided: Dyspnea,pinksputum,productivecough,pulmonaryedema Rightsided: Distendedneckveins,ascites,ankleedema,hepatomegaly LabData: LeftcardiacfunctionSwanGanz RightCardiacFunctionCVP N.Dx: AlteredtissueperfusionanddecCO Priority: ToIncCO Positioninsemifowlers AdministerdrugsasprescribedDigitalis,Vasodilators,Diuretics *Morphinedecvenousreturntotheheartperipheralvasodilatingeffects DietLowNa,LowCholesterol

34

Assessbreathsounds,edema,heartsounds HYPERTENSION =SilentKillerdisease Hypertensivedisordersofpregnancy =PersistentelevationofBPabove140/90 =120/80Prehypertensive =110/70normal RiskFactors: FamilyHx Age Blacks Obesity Stress Smoking Types: 1.)EssentialUnknown 2.)BenignUnknown/Longduration 3.)MalignantAcute,shortduration 4.)Secondary?Duetomedicalcondition Complications: OccipitalHA RetinalHemorrhage PedalEdema 4commoncomplications: CAD CVA CRF CHF

Lab:Incincholesterol,IncLDL,IncTAG N.Dx:AlteredhealthmaintenanceTxisprolonged =Vasodilator,Antilipemicagents *CommoncauseofconcernBronchospasm,Declibido DietDecNa,Deccholesterol NONPHARMACOLOGICREGIMEN StressMx:Exercisedeepbreathing,walking,stressfreehobbies(likewalkingbythebay) HPNinpregnancyUnknown =GeneralizedvasospasmduetovirusH.Lualba nd =2 trimester =B420wksAOGH.Mole/GTD =after20wksAOGPIH =Beforeandafterpregnancychronichypertension HYPERTENSIVED/OOFPREGNANCY o IncBP

35

PREECLAMPSIA o IncBP o Edema o Proteinuria: Mild:BP140/90 Protein<5gm/24hrs Severe:BP160/110&above Protein>5gm/24hrs o Mx:Darkenedroom IncCHONdiet MgSO4:Antidote>CaGluconate ECLAMPSIA o IncBP o Edema o Proteinuria o ConvulsionbleedingHELLPSyndrome(hemolysis,elevatedliverenzyme,lowplatelet manifestedwith petechiae PVD

Color Edema Nails Pain Pulse Temperature Ulcer

ArterialOcclusion Pallor ()orminimal Thick&brittle *IntermittentClaudication () Cold Dry

VenousOcclusion Ruddy Severe Normal Homanssign Normal Warm Wet

BUERGERS (ThromboantgitisObliterans) Acute A&V Male Lowerex Smoking Inflammationofarteriesandveins

RAYNAUDS DISEASE Intermittent arteries Female Upperex(97%)toes,ears,LE(3%) Cold Vasospasmofarteries

ARTERIOSCLEROSIS OBLITERANS Chronic arteries Male Upper&Lowerex hardeningarteries

Pain IntermittentClaudicationIntermittentcolorchanges (Pallor,Cyanosis,Redness) Labdata:PainlessDopplerUTZ N.Dx:Pain&alteredtissueperfusion Priority:AntiHPN,Vasodilator,Anticoagulants Instructions:Avoidsmoking,swimmingincoldwater

36

PULMONARYEMBOLISM Aclotlodgesinoneofthepulmonaryarteries RiskFactors: 1.) 2.) 3.) 4.) VATrauma Hypercoagulation Arrhythmia Thombosis

S/Sx: Anxiety/Agitation Dyspnea Restlessness Tachycardia Tachypnea ChestPain *Crackles LabData:PerfusionLungScan N.Dx:Pain,Ineffectivebreathingpattern Priority:PositioningRightsidelying AdministerAnticoagulant ABDOMINALAORTICANEURYSM Weakeningofthewallsoftheaorta Congenital Angina ChronicHPN Types: 1.) Fusiformbulgingofbothsidesofbv 2.) DisectingDissectedinnerwallofbv 3.) Saccular formsapouchorsac S/Sx:Assymptomatic PulsatingAbdominalmass LowBackPain IncBPofUe,DecBPinLE Labdata:Aortography,XRay N.Dx:RiskPoorinjuryalteredtissueperfusion SafetyMostAbdominalPalpation Prepareptforsurgerythatwillinvolvegrafting Aftersurgeryassessfordistalpulses KAWASAKISDISEASE Acutesystemicinflammationofthevascularsystem Heart&bloodVessels CommoninJapanese,toddler&preschooler Unknown S/Sx:Highspikingfeverfor5daysofmore Strawberrutongue,palmardesquamation LabData:2DEcho,ECG N.Dx:Alteredtissueperfusion,DecCardiacoutput Priority:Txissupportive,ASA Diet:ClearLiquid DischargeInfection:TeachPt.CPR 5:1Pedia 15:2Adult 30:2

37

1.ToAssessriskofdevelopingmitralvalvestenosisinpt.Whatshouldthenurseaskthept? A:Didyouhavestreptococcalinfection 2.HowtoassessintermittentClaudication: A:Askthepttowalkandnotepresenceofpain 3.WhatshouldthenurseprepareatbedsidewithPVC A:Xylocaine 4.Priorityinptwithcompleteheartblock A:Alteredtissueperfusion 5.GoalofCarewithatrialfibrillation A:IncCO 6.Coomoncomplicationofsicklecellanemia? A:CVA 7.Signsofleftsidedheartfailure A:Dyspneaonexcretion 8.WhenplanninganexerciseprograminptwithHPN,Nurseshouldask? A:Howdoyouspendyourleisuretime CYSTICFIBROSIS Inheritedmultisystemdiseaseaffectingtheexocrinegland Autosomalrecessiveeachpregnancy(Disease25%,trait50%) ExcessiveMucousproductionMade=Sterility,Female=Diff.inconcerning S/Sx:Initial:Abdominaldistention MalabsorptionSyndromeSteatorrheaFoulsmellingfatty,stool Saltywhenkissed Lab:PilocarpineSweattest RespiratoryTherapy:BlowingExerciseTrumpetBlowingBubbles GITherapy:PancreaticEnzymePancreasViokasewitheachmeal&snacks Referptspreventsgeneticist Pt.GrowsOB PNEUMONIA MycoplasmaPneumonia(pedia),Legionnairesdisease(elderly,alcoholic,immunosuppresion) InflammationAllveoliExudate,Consolidation Viral,Bacterial,Rickettsia S/Sx:5Cardinalsigns&symptoms 1. Fever 2. Sputum 3. PleuriticChestPain 4. Chills 5. Cough

38

PNEUMONIA

Viral:

Lowgradefever Thin&waterysputum WBCeithernormalorslightlyincreased

Bacterial Highgradefever Rustysputum WBCseverelyincreased Labdata:ChestXray,sputumexam,ABGanalysis N.Dx:ImpairedGasExchange IneffectiveAirwayclearance IneffectiveBreathingpattern Priority:BedRest,IncOFI,Administermedsasordered:antibiotics CROUP ACUTELARYNGITIS Toddler Larynx S/Sx: Cough:Barking,metallic Stridor:Present Wheezing:Absent Fever:Absent LabData: ThroatSwab PE Xray N.Dx: Infection,Ineffectivebreathingpattern Priority:Txofinfection Multidrugtherapy OPD(ObstructivePulmonaryDisease) Narrowingandobstructionoftheairway Emphysema overdistendedalveoli Bronchitis inflammationofbronchioles Smoking RE,TACY,TACHYDC BarrelChest GelatinousSputum Inccoughing Whitishsputum Orthopnea Asthma excessivemucus LTB Infant&toddler Viral&Bacterial InflammationoftheLarynxandtrachea Harsh&Brasky Present Absent LowGrade Xray Throatswab PE BRONCHIOLITIS Infant<6mos (RSV) Bronchioles Paroxysmal&Hacking Present Present Moderatetohighgrade Xray ELISA Throatswab PE

39

LabData:Xray,ABGAnalysis N.Dx:IneffectiveBreathingPattern IneffectiveAirwayClearance Orthopneic SemiFowlers PrinciplesinNursingCare: Bronchodilator Rest Oxygenlowflow Nebulize ChestPhysiotherapy HighFowlers IPPBIntermittentPositivePressureBreathing Aerosol LiberalFluidIntake Complication: CorPulmonale RightVentricularHypertrophy Pneumothorax Spontaneous Ruptured Bullae/alveoli Open Chestinjury Tension Trauma Aminophylline Steroid Theophylline HistamineAntagonist Mucolytic Antabuse Bronchodilators Activity:Softball Baseball

Increasetensionandpressure Thoraciccavity Lungcollapse ()breathsounds Dyspnea Pain 3waybottlesys PointersforRespiratory: 1.) MistPriority? A:Changethelinenandclothingtokeeptheptdry. 2.) Goalofcareforchildwithbronchiolitis? A:MinimizeO2expenditure 3.) Pancreaseisgivenwithmeal 4.) PatientwithTB WhatisthepurposeofNGT? A:Toaspirateswallowedsputum 5.) S/Sxthatindicatesemphysema? A:Barrelshapedchest 6.) DevelopmentofEdema? A:Moistandnoisybreathing 7.) CommonriskfactorforLegionnairesdisease? A:Immunosuppression 8.) MycoplasmalPneumoniaismanifestedby? A:Fever&productivecough

40

PKU o Inheriteddisordercharacterizedbyabsenceofphenylalaninehydroxylase(PH)whichconvertsphenylalanine totyrosine(precursor) melaninforhair,eyes,skin o Normallevel=2mg/dl,4mgmayindicatePKU,8mgconfirmsPKU o Autosomalrecessive o PhenylalaninistoxictothebrainandcausesMR S/Sx:Asymptomaticatbirth:Diarrhea,Anorexia,Lethargy,Anemia,skinrashes N.Dx:Knowledgedeficit Alterednutrition Riskforinjuryseizure HealthTeachings: LowPhenylalanineuptoadolescence910y/o RefertoGeneticistsandnutritionist Producelistoffoodsthatsisallowedandnotallowed

HASHIMOTODISEASE o o o o o CongenitaldeficiencyinT3andT4 S/sxAsymptomaticmaternalhormonaltransfer 23moss/sxappear Behavioral:Apathy,wellbehavedbaby Physical:Largetongue,shortstructure,retardedgrowthMR

Labdata:DecT3andT4 N.Dx: Knowledgedeficit Riskforactivityintolerance Alteredgrowth&development Priority:AdministerSynthroid,singlemorningdoseforever Report:Tachycardia(palpitations) Insomnia Nervousness *Providewarmenvironment *Refertospecialeducationcenter PANCREAS ALPHACELLS Glucagon BETACELLS Insulin

MODY (MaturityonsetDiabetesinyoungadults) CombinationofIDDM&NIDDM nd Pregnancy2 trimester DevelopedplacentasecretesHPL (Humanplacentallactogelcounteracts insulin Gestational:(Whitesclassification) Types: A:ChemicalDM: B:onset:>20y/o C:1019y/o

Absence IDDM(TypeI) Juvenileonset Ketosisprone Thin

Deficiency NIDDM(TypeII) Maturityonsetafter35 NonKetosisform Obese

41

D:<10y/o D1:<10y/o D2:>20y/o D3:Beginningretinopathy D4:Hardeningarteries D5:HPN E:Pelvicarteries F:Retinopathy H:Cardiopathy R:Retinopathy T:Transplantkidney Absenceordeficiencyininsulinaffects,CHO,Fats&CHONmetabolism Insulinfacilitatesentryofglucoseintothecell Ifthereisnoinsulinglucoseremainsoutsidethecellhyperglycemiafluidsareattractedtocell&blood Cellsdehydrated(brain)compensatorymechanismPolydipsia Cellsdehydrated(brain)IncglomerularfiltrationratePolyuria leadstoweightlosscellstonesbrain polyphagia LabData:FBS,GlycosylatedHgb,Hemoglucotest N.Dx: Knowledgedeficit AlteredNutrition AlteredElimination RiskforInfection Priority:Tomaintainnormalbloodsugar Diet:5070%CHO,2030%Fats,1020%CHON Wellbalanceddiet nd Insulin:TypeI,pregnant2 trimesterIncdose AntiDiabeticAgentssulfonylreasCI>sulfaDrugs Bloodsugaramandpm EnsureAdequatefoodintake Transplantofpancreaticcells ExerciseModerate ScrupulousFootcareAvoidbarefoot,avoidsyntheticshoesIndicated:Footpowder,snugglyfittingshoes,cotton socks,visitpodiatristatleastonceayear Complications: Hypoglycemia:BloodSugar<150mg/dl RF:toomuchinsulin,missedmeal,exercise S/Sx: Diaphoresis DecreasedLOC Diffinproblemsolving Hyperglycemia:Bloodsugar>140mg/dl RF:Toolittleinsulin,Incfoodintake,pregnancy, Infection,stress,surgery TypeI typeII DKA HHNK Acetonebreath IncGIs/sx DeH2O DeH2O Warmskin IncserumOsmolality 3Ps 3Ps Kussmaulsbreathing TX:Airway,FluidandInsulinrapidactinginsulin

Tx:Simplesugar

OtherComplications: 1.) Microangiographydamagetosmallretinalbloodvessels 2.) AtherosclerosishardeningofarteriesHPN 3.) NeuropathyKidneydamage 4.) RetinopathyOpthalmopathydamagetonerves 5.) Peripheral/AutonomicDecnerveimpulsetransmission

42

PITUITARYGLAND ADH FluidRetention Deficiency DiabetesInsipidus RiskFactor S/sx: LabData: Trauma Surgery Polyuria(21L/day) Polydipsia Fluiddeprivationtest NPOX12hrs Concentratedurine SpecificGravity:<1.005 CheckspecificGravity Exercise SIADH Trauma Tumor

Vasopressin Depressin Lepressin Monitorandoutputandspecificgravityofurine Goalofcare:ExcretionoffluidDiureticsandantiHPN GrowthHormone Ant.PituitaryGland Promotesgrowth Deficiency DwarfismMahal AchondroplasiaNanusSyndromeDagul

Fluidretention DilutionalHyponatremia CheckSodium

Excess *BeforeclosureofgrowthplateGigantismTaller,slender MarfansSyndromeGeneticd/o,a.Dominantspined/o ScoliosisCardiacproblem *AfterclosureofgrowthplateAcromegallyenlargementof Extremities *Incgrowthhormoneandglucose ADRENAL

Outer Cortex Glucocorticoids Gluconeogenesis Def. Addisons Mineralocorticoids Naretention Excess Cushings Excess Conns Syndrome Commonssyndrome Aldosteronism LabData:IncVMA27mg/dlin24hrs Avoidvanillacontainingfoods,14hrsbeforethetest

Middle Medulla Epinephrine Norepinephrine fight/flightresponse Tumor Pheochromocytomaexcessepiand norepinephrine HPN,H/A Inchyperglycemia Hypermetabolism

43

ADDISONS Deficiency Glucocorticoids Mineralocoticoids RF:Autoimmune Surgery S/Sx: Hypoglycemia Hyponatremia Hyperkalemia Hypotensionshocklike Brownskinpigmentation TruncalObesity Moodswings Facialhirsutism Buffalohump MoonFacie

CUSHINGS Excess Mineralocoticoids Tumor Hyperglycemia Hypernatremia Hypertension TruncalObesity Moodswings Facialhirsutism Buffalohump MoonFacie

CONNS Excess Mineralocoticoids tumor Hypertesnsion Hypernatremia Hypertension TruncalObesity Moodswings Facialhirsutism Buffalohump MoonFacie incNa&decK,IncBP AntiHPN Diuretics DecNa,IncK

Glucocorticoids

MaintainFluidandelectrolyteBalance Steroids steroidsinhibitor *FludrocotisoneFlorinef Mitotaine Decs/sx: NormalNaandbloodsugar Diet: IncNa,DecK DecNa,IncK ClientTeachings: Medsforlife Pronetoosteoporosis Avoidcrowdedareas Excessivepoorwoundhealing

THYROID T3,T4 BMR Deficiency Hypothyroidism Cretinism Myxedema RF:Autoimmune,tumor S/Sx: Facialedema Intolerancetocold Hypometabolism LabData: DecT3,T4,IncTSH Activityintolerance UthyroidstateNormal Givethyroidsupplement Synthroid SE: Insomnia Nervousness Palpitation Excess Hyperthyroidism Gravesdisease Basedowsdisease Parrysdisease CALCITONIN DepositionofCainthebones

Exopthalmos Goiter Hypermetabolism Intolerancetocold IncT3,T4,DecTSH Riskforinjury Uthyroidstate Antithyroiddrugs Propylthiouracil Agranulocytosis(Fever,Soarthroat)

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Diet: DecCalories Warmenvironment THYROIDSURGERY Preparation

IncCalories Coldenvironment

Postoperative Monitorcomplication 1.Hemmorrhagebruises 2.Laryngospasmtracheostomy 3.Damagetolaryngealinabilitytospeak,aphonia 4.TetanyDecinCa>Tingling,chvostek,Trouseausign 5.Thyroidcrisis Complications:Fever,IncHR,checkVS

Lugolssolution(2wksbeforesurgery) Decsize&vascularityofthyroidgland Giveinstrawanddilutedinwaterorapplejuice S/sxofiodismMetallictaste

PARATHYROID IncCaintheblood Hypothyroidism Surgery S/Sx Early:Tingling,chvostek,Trouseausign N.Dx: Riskforinjury GiveCasupplements IncCaindiet Renalcalculiformation LabData:IncCainblood N.Dx:Riskforinjury Priority:Surgery Mx:IncOFI Hyperthyroidism Tumor Pain,bonedestruction,fracture/osteoporosis VonRecklinghausendisease

Pointers: 1.ManifestationsofKetoacidosis: A:Rapidanddeepbreathing 2.PostthyroidectomyTetanyofhands,feetandmuscletwitching,thenurseknowsthedoctorwouldorder? A:CaGluconate 3.W/coftheff.indicateshypothyroidism? A:Intolerancetocold 4.InPKU,whichisnotindicated? A:MilkShake 5.Whichoftheff.manifestationindicatesacomplicationpostthyroidectomy? A:Tachycardia 6.Whichoftheff.interventionsisappropriateforaptwithAddisonsdisease? A:MonitortheBP 7.Insulinwasgivenat8am,whendoyouexpecthypoglycemia? A:Beforelunch 8.InPTUanexpectedoutcomeisa? A:DecinPR 9.Hypothyroidism bestquestion? A:Doyoutire? 10.Whichoftheff.dataneedstobeassuredinheadinjury? A:DecurinespecificGravity

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NEPHROTICSYNDROME Congenital Autoimmune Inabilityofthekidneystomaintainfluidbalance *hyponatremia S/Sx: NormalordecinBP PeripheralEdemasubsidesattheendoftheday Frothyurinecolor

ACUTEGLOMERULONEPHRITIS Acquiredsorethroat Autoimmune Kidneydamage

IncBP Progressiveperipheraledemaattheendoftheday teacoloredurine/cola

LabData: MostsignificantdataProteinuria=>10mg/24hrs Proteinuria=<10mg/24hrs ()Colloidosmoticpressureedema IncASOT N.Dx: FluidVolumeexcess Riskforimpairedskinintegrity Mx: Goalofcarepromotefluidbalance Restrictedfluid Frequentlyturnclient Steroids AGN:AntiHPN DecNa,IncCHON DecNa,DecCHON

WILMSTUMOR Congenitaltumorofkidneys unilateralleftkidney palpableonabdomen commoninchildren<5y/o (+)HPN,Hematuria Riskforinjury PromoteSafety Prepareptforsurgery&chemotherapy Avoidabdominalpalpation CYSTITIS Ascendinginfection BladderUretersKidneyspyelonephritisCVAtendency RF: bubblebath Silkunderwear Prolongeddriving Catheterization S/Sx: Burningsensation LabData: Urinalysis IncWBC Incglucose Tx: Treatinfection antibiotics Acidashdiet IncOFI Avoidriskfactors

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RENALFAILURE ACUTE Suddencessationofkidneyfunction RF: Pre Renal Deccirculationof Bloodvolume S/sx Oliguric Phase Decurineoutput <400ml Intra Renal diseaseofkidney Post Renal obstruction stone Recovery Phase 12yrs CHRONIC Progressive/irreversibledestructionofkidneytissues Scarformation AGN,NS

Diuretic Phase polyuria,decNa&K

1.Decrenalreservepolyuria,nocturia,polydipsia 2.RenalinsufficiencyIncBUN&creatinine 3.RenalFailureHPN,RenalDamage 4.ESRDAzotemia,uremia LabData: IncBUN&Crea N.Dx: Fluid&electrolyteimbalance Priority:Fluidrestrictions Meds:Epogentopreventanemia Amphogelpreventhyperphosphatemia Diuretics,AntiHPN,Digitalis Diet:DecChon Mx:Dialysis:3Xaweekorevery48hours

N.Dx: Fluid&electrolyteimbalance Priority:Restorecirculatingfluids Monitorintakeandoutput Responseofclientontherapyoutput,BP Meds:Diuretics,DecNadiet,AntiHPN,digoxin

DIALYSIS Hemodialysis DialyzingagentDialyzingMachine Access Fistula shunt internalaccess externalaccess anastomisisofa&v palpateforthrillsandauscultatebruit Complications Disequilibrium Rapidremovalofwasteproduct Fluidsandelectrolytes GI CNS NAVDA H/A Dizziness Restlessness ReporttoMD DialysisEncephalopathy Aluminumtoxicity S/Sx:dementia,dizziness ReporttoMD Peritoneal DialyzingagentPeritoneum Access Tenkhoffcatheter assessrigidabdomenperitonitis

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BPH Glandularenlargementoftheprostate Afterage40,male S/Sx: Decsize&forceofurinarystream Nocturia Dysuria Frequency,urgency,hesitancy LabData: DRE@age40 Priority:PromoteUrinaryeliminationPrepareforsurgery TURPnoincision Suprapubic Retropubic abovethebladder belowthebladder

Perineal causesimpotence

Pointers 1.Anelderlywitholiguriaandflankpainmayindicateaproblemscausedby? A:Intakeofneomycin 2.Whichlaboratorydataneedstobereported? A:urinespecificgravityof1.004 3.12hrsafterTURPtheptcomplainsofspasm A:Checkpatencyofretentioncatheter. 4.A2y/oboywithNephroticSyndromewithperiorbitaledema&frontaledemawhatwillbetheessentialnursing measure:A:turnptfrequently 5.Whichoftheffisacommoncomplicationofchronicrenalfailure? A:Anemia 6.AptwithNephroticSyndromeasksWhyamIgainingweight?thebestreponseis? A:youhavesodiumretentionthatattractswater 7.Duringhemolysis,ptwithHAandvomiting,restlessandconfused,heishaving? A:Disequilibriumsyndrome 8.Afterperitonealdialysisthereturnflowwithdialyzatesolutionisinadequate,Whatshouldthenursedo? A:Turnptfromsidetoside. 9.APriorityN.dxtoaptwithrenalstones? A:Pain

OTITISMEDIA Infection ofmiddleear URTI Faultyfeeding swimmingindirtywaters Pain,fever,earache LabData:PE,otoscope,bulgingtympanicmembrane N.Dx:Painantibiotic,decongestant,Pseudafed Chronic:myringotomytubeinsertion RETINALDETECHMENT o Separation o Sensorypigmentretina o Aging40y/o o Trauma o S/sx:visualfloaterspainless Cobwebs,veillike,floatingspots o LabData:Opthalmoscopy,PE o N.Dx:Riskforinjury o Priority:Safety,bedrest,affectedsidetowardsthebed o Scleralbucklingusinglasertocreateascar o Avoidsuddenheadmovement,bendingandblowingofnose o Surgery:

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Trabeculoplastytrabecularmeshworklaseroutpt Ttrabeculectomytrabecularmeshworkremovalinptfor12days o Avoidbendingandsuddeneyemovement o Report:eyepainandbleeding GLAUCOMA o IncIOP o OpenAngle:ChronicIncaqueoushumor o ClosedAngle:Acute forwarddisplacementofiris o Aging>40y/o o Familial o tunnelvision o Gunbarrelvision o halosaroundlights o Lossofperipheralvision o Blindness o LabData:Tonometry,(gonioscopydifferentiateopenfromclosedangleglaucoma),perimetry>visualfields o N.Dx:riskforinjury,safety,decIOP o Meds:Myoticspilocarpine o CI:Midriatics CATARACT o Opacityoflenses o Poorcolorperception o Painless o Aging>40y/o o Prolongedsteroids o LabData:Opthalmoscopy()redlightreflex o N.Dx:Riskforinjury o Surgery: Peripheraliridectomy holeinlenscataractissuctioned Photoemulsificationneedlelikestructureinsertedintothelens>crushcataract o Avoidbendingandsuddeneyemovement o Report:eyepainandbleeding MENIERESDISEASE Imbalanceintheendolymphaticfluids innerear RF: Highaltitudes(pilotsanddivers) s/sx: Hearingloss Tinnitus Vertigorevolvingmotion LabData: Caloricstimulationtest N.Dx: Riskforinjury Intervention: Safety Positionsupineorflat Diet:LowNa CI:Streptomycinototoxic Meds:DIAMOX Pointers: 1.Posttrabeculoplastyeyepain. OTOSCLEROSIS Hardeningofthebonesintheinnerear affectedstapes Aging diffincommunicating tinnitus conductivehearingloss WeberandRhinestest Impairedcommunication establishcommunication stapedectomymobilizestapes postsurgery:avoidblowingofnose avoiddeepdiving avoidflyinginsmallairplanes

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A:CallMD 2.Ptwithtunnelvision,N.Dx? A:Incriskforinjury 3.Whichdrugwillhelpdecaqueoushumor? A:DIAMOX 4.PostCataractextraction,whatistheposition? A:Onunaffectedsidetodecedema 5.Whichinterventionwillhelppreventlossofvisioninglaucoma? A:Takingthemedscorrectlyasordered 6.Whichdescribestrabeculoplasty? A:Surgicalinterventionthataimstocreateapassagewayfortheblockedfluid.

DUCHENNESMUSCULARDYSTROPHY geneticallytransmitted Xlinkedrecessive(mothertoson50%disease, Mothertodaughter25%trait) S/sx: Gowerssignarmsusedtopushbodytostandup Waddlinggait Difficultyinrunningandclimbing1to2 Progressiveweaknessrespiratoryparalysis LabData:EMG,PE N.Dx:Ineffectivebreathingpattern Impairedphysicalmobility Preparetracheostomyset Referparentstogeneticists refertoPT Treatsymptoms CEREBRALPALSY nonprogressive(fixed)d/o neuromuscularsystem uncoordinatedmovements relatedtobrainanoxiaandprolongedlabor S/sx: Exaggeratedreflexes Earlypatternofhanddominance1012months poorposture Archingofback Frequenttonguethrusting scissorgait LabData: CTScan Musclebiopsy N.Dx: Riskforinjury ImprovedPhysicalintegrity Alterednutrition Priority:PromoteSafety&mobility Assistambulation Support:crutches,cane,walker,legbraces Drugsmusclerelaxants,anticonvulsants SurgeryreleaseoftendonofAchilles Foodsthatsticksonspoon

ERBDUCHENNEPARALYSIS acquired Birthtrauma(hyperextensionofshoulder) BrachialPlexusupperplexus Reversible,recoveryafter3mos Klumpkesparalysislowerplexus

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CSFFLOW rd th LateralVentricles ForamenofMonroe3 VentricleAqueductofSylviusForamenofLushka&Magendie4 VentricleSubarachnoidspaces HYDROCEPHALUS InterruptionofCSFflow Notadisease Manifestationd/o ArnoldChiariMalformationElongationofbrainstemObstructstheflowofCSF DandyWalker atresianarrowingofforamenofLushka&MagendieCSFflow Excessiveproduction(communicating)orobstructionofCSF(noncommunicating) S/Sx:Projectilevomiting,irritability,enlargedhead(Normal3335cm),Sunseteyes,separationofsutures,seizure) Bossingsignpronouncedforehead Macewenssigncrackedpotpercussionofhead Labdata:CTScan,MRI N.Dx:Riskforinjury Priority:Safety,Seizureprecaution Meds:Anticonvulsants Position:SemiFowlers Lowfowlers Surgery:Insertionofventriculoperitonealshunt CheckIncinICP Measureheadfrequently SPINABIFIDA Failureofspinalprocessestofuse neuraltubedefects Occulta:Dimpling,tuffofhair,lumbosacralarea Cystica:MeningocelCSF&meniges,MyelomeningoceleCSF,meninges,spinalcord LabData:PE,MRI AlphaFetoCHONanalysisIncreased Normal1530 N.Dx:Riskforinfection,Impairedmobility Sidelyingorpronebestposition Coverwithwetsterilegauze Surgerywithin48hrspreventparalysisofLE Aftersacisclosedmayleadtohydrocephalus Tapemeasure@bedsidetomeasurehead

IncreaseICP ICPmorethan15mmHg Normal010 1120 mild 2130 moderate 31andabovesevere Maybeduetotrauma Spaceoccupyinglesion Acongenitaldefect S/Sx: Early:DecreasingLOC Late:VSchanges,Cushingstriad,widenedPP,DecPR,DecRR LabData:Subdural/intravascularmonitoring N.Dx:Riskforinjury

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Priority:Safety,headofbedelevated,evaluateLOC,promoteapatentairway Dischargeinstutions:meds,mitoring,seizureprecaution BACTERIALMENIGITIS Infectionsinflammationwithmenigitis N.Menigitides InfluenzeVirus HIBVaccine S/Sx:IncICP,Brudzinskissign,Kernigssign LabData:CSF,DecSugar,IncWBC,IncProtein NDx:Riskforinjury,Riskforinjection Meds:Antibioticsasprescribed Precaution:RespiratoryDroplet Complication:HearingImpairment AudiologistScreeningandtesting REYESSYNDROME Toxic Encephalopathy&Hepatopathy Fattyinfiltration CNSandLiver V.VaxrelatedtoReyes TriadSymptoms:Fever,DecLOC,Bleedingtendencies Stages: 1.) Stage1=Confused 2.) Stage2=Lehargic 3.) Stage3=Decorticate 4.) Stage4=Decerebrate 5.) Stage5=Comma Diagnostic:Biliaryfxntest,bleedingtime,clottingtime,NeuroassessmentGCS NDx:Riskforinjury Priority:Safety Bleedingprecaution,clottingtime,NeuroassessmentGCS Vivax(+)chickenpoxReyes SEIZURE Abnormaldischargeofelectricalimpulseinthebrain RF: Metabolicd/oDelirium Alcoholismwithdrawalsymptoms Intakeofdrugs&trauma S/Sx: Types 1.) Absence/petitmalbriefperiodsofnonactivity 2.) JacksonianStartsonbodypartstowholebody 3.) GrandmalTonic:gen.contractions,Clonic:alternatingcontraction&relaxation S/Sx:Dura feelingofuneasinessbeforeseizureandLOCandconvulsion. N.Dx:IneffectiveAirwayClearance Riskforinjury Smalpillowatthebackofheadorlap Meds:Anticonvulsants,Dilantin RefertoNeorologist Subs.Abusescreening EEG,MRI,CTScan Precaution:Avoidextremes Avoidemotionalstress Lifetimeanticonvulsants

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CVA SuddencessationofbrainfunctionsduetodecO2 RF:Thrombosis,embolism,hemorrhage&infarction Progression: 1.) TIAbriefneurologicdeficits30secs24hrs 2.) Strokeinevolutionbodyweakness/facialweakness 3.) Completedstroke FrontalLobepersonality,speechchangesBrocasaphasia ExpressiveAphasiaInabilitytosaytherightwords TemporalMemory,WernickesAphasiaInabilitytocomprehend ParietalLobesensation&orientation OccipitalVisualdisturbance S/Sx:IndicativeofComplication HemiplegiaParalysisofrightorleftsideofbody HomonymousHemianopsia EmotionalLabilityMoodswings AphasiaExpressiveandreceptive DysphagiaSwallowfoodatleasttwice C4C5deccusationofspinalcord RightlesionLefteye,rightface,Leftbodyaffectation UnilateralNeglect LabData:InccholesterolNormal200 EEG,MRI,CTscan N.Dx:Ineffectivebreathingpattern Headofbedelevated RefertoPT&OT Diet:LowNa,LowFat Meds:Anticonvulsants,vasodilator,diuretics

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NEUROMUSCULARDISEASE

GBS PNS Inflammation&destructionofPNS Autoimmune viralinfection Nogenderrelatedfactors NMJ

MG CNS

MS

ALS(LouGehrig) Upper&LowerMotorNeuron Autosomaldominant Male&Female

Autoimmune(early male2040 y/o,latefemale>50y/o) Deficiencyinacetylcholinereceptor sites descendingmuscleweakness fromfacedownward Ptosis Difficultyinchewing Decreasevoice

Whites/females DemyelinationofneuronsinCNS BrainandSpinalCord

S/Sx: Ascendingordescendingmuscle paralysis Mixture RespiratoryDepression Lab.CSFAnalysisIncCHON N.Dx: Ineffectivebreathingpattern Priority: Promotepatentairway

Preparetracheotomyset@bedside steroids RefertoRespiratoryTherapist

Diplopia Ptosis Impairedsensation Impairedsexualfunction Generalmuscleparalysis CI:Talkinglongrespiratory Lab:MRI,localizesareasofplaque depression formation Diagnostic: N.Dx: Tensilonshort30secslastsfor5 Ineffectivebreathingpattern mins Sensoryperceptualalteration Drugs: Priority: NeostigminelifetimeAntidote Maintainpatentairway ATSO4 Meds: steroids Musclerelaxants Bladderstimulant Complications: Avoidhotorcoldshower Crisis Assistdietinambulation Myesthenic:DecMeds *Bladderretrainingprogramself Neostigmine catheterization Cholinergic:IncMedsATSO4 Handwashingtoprevent ascendinginfection RefertoPT&OT

Dysphagia

Lab:EMG,CTScan,MRI N.Dx: Ineffectivebreathingpattern Priority: Airway Preparetracheostomyset

Supportiveandpreventive Advancedirective&livingwill

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