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Perioperative Nursing
3 phases:
Pre-operative
Intra-operative
Post-operative
Pre-operative Period
Used to physically and psychologically
prepare the patient for surgery
Nursing Diagnosis:
Anxiety
knowledge Deficit
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Pre-operative Period
Diagnostic evaluation:
- CBC, Urinalysis (standard)
Nursing Responsibilities
- Encourage the patient to verbalize feelings
- Encourage to participate in decision
Nursing Considerations
(Informed Consent)
Patient signs own consent if he or she is
Side rails up
Antibiotics on call to OR
Sample Question
The nurses signature as a witness on an
Skin Preparation
Scrub with antimicrobial agent
Hair should remain unless it
Day of Surgery
AM care
Pre-operative checklist
Remove nail polish, jewelry, contact
lenses, dentures
Give valuable items
Chart disposition of items
Proper identification: Check band for
secureness and legibility; surgical site
may be marked to prevent error
Surgical team
Surgeon
- the captain
- specialized in surgery
Anesthesiologist
- administer anesthesia
- alleviates pain and
promote relaxation/
homeostasis
Assistants
Circulating nurse
- senior nurse
- errand person
Scrub nurse
junior in OR
participates directly
supply instruments
maintain asepsis
depends on the
circulating nurse
Intra-operative Period
Types of Anesthesia
- Regional anesthesia
- General Anesthesia
- Local Anesthesia
Types of Anesthesia
Regional- intact consciousness; loss of
Regional Anesthesia
- Uses: Lower legs, abdominal or
-
perineal area
Nursing Responsibilities:
Assess VS
Assess for return of sensation and
motor function
Keep FOB at least 3-4hrs
Provide adequate hydration
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Types of Anesthesia
General anesthesia- produces
Nursing Responsibilities
- Monitor safety of the patient
- Have resuscitative equipment nearby
Sample Question
Which nursing action is the highest
Post-anesthesia Care
Unit
Monitor ABC
Airway and Breathing- O2 saturation,
Post-operative
Complications
Altered Respiratory Function
- Causes: airway obstruction, anesthesia,
atelectasis
* Atelectasis is the most
common cause of increased
body temperature during the
1st 24hrs of surgery
Post-operative
Complications
Nursing Responsibilities:
Maintain patent airway
- DBCE, use of IS ( ventilate distal
Post-operative
Complications
Altered Cardiac Output
- May lead to shock due to fluid volume
Post-operative
Complications
Altered
Mental Status
- Monitor LOC- GCS
- Observe for decreased reflexes
Nalbuphine)
- Reposition every 2hrs
- Reduce anxiety and teach relaxation
techniques
- Medicate as ordered (RTC); if too much
narcotics
Antidote: ______
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Post-operative
Complications
Altered GI function
- Causes: Anesthesia, bowel manipulation,
-
paralytic ileus
Observe for n/v due to decreased peristalsis
Observe for absent bowel sounds- withhold
food and fluids until bowel sounds return
Maintain IV access and administer fluids and
electrolytes
Monitor for abdominal distention and
discomfort
NGT drainage as needed
Gradually change the diet of the patient
Ambulate as soon as possible
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Post-operative
Complications
Decreased
UO
- Monitor UO- should resume after
Sample Question
Which statement by a client indicates a
Post-operative
Complications
Impaired Circulation
in calf muscles
Provide anti-embolic stockings to
compress superficial veins and increase
blood flow to deep veins and prevent
venous pooling
Dont put pressure on popliteal area
Dont massage the patients legs
Promote ambulation ASAP
Treat thrombophlebitis by bedrest,
anticoagulant drugs
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Assessment
Risk Factors
Non-modifiable
Age
Gender
Race
Heredity
Modifiable
Stress
Diet
Exercise
Cigarette
smoking
Alcohol
HPN
Hyperlipidemia
DM
Obesity
Diagnostic Tests
Cardiac enzymes
- CK-MB- elevation indicates myocardial
damage- elevates within 4-6hrs; peaks in
18-24hrs
- LDH- occurs in 24 hrs and peaks in 48-72
hrs
- Troponin I- most accurate
Complete blood count- WBC, RBC, H&H
Electrolytes- K, Na, Ca, Phosphorous, Mg
BUN and creatinine
CXR
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Sample Question
If the client asks the nurse to explain
Time
Most specific for heparin tx
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Diagnostic Tests:
1.ECG- a common non-invasive
procedure that records the electrical
activity of the heart
Cardiac Catheterization/
Angiography
Coronary artery visualization-
Cardiac catheterization
ANGINA
Chest pain that results from myocardial
Angina: Causes
- Activity that increases metabolic
demands
- ANY INCREASE IN HR
INCREASE
OXYGEN DEMAND
Vigorous exercise
over-eating- INCREASE METABOLISM
INCREASE HR
Stress
Sex
- Atherosclerosis, thromboembolism
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Sample Question
A client with angina complains that
ANGINA
Assessment:
- Pain- substernal, crushing or
Angina
- Diagnostic evaluation:
- Increased cholesterol, LDL and
triglycerides
- Cardiac enzymes usually WNL
- Coronary arteriography shows
narrowing of coronary arteries
- ECG- ST segment depression, T-wave
inversion
Nursing Management
- Encourage to adhere to diet
-
Medications
- Administer medications as ordered
Angina Pectoris
Treatment
Percutaneous Transluminal Coronary
Angioplasty (PTCA)
Intravascular Stenting
Done to prevent restenosis after PTCA
Given coumadin, ASA (prevent clotting)
Stent
Myocardial Infarction
Thrombus
Emboli
Atherosclerosis
Myocardial Infarction
Myocardial Infarction
Reduced blood flow in one of the
coronary arteries > ischemia, injury and
necrosis
Possible Causes:
- Coronary artery occlusion, spasm,
stenosis
Risk factors:
- Same risk factors as in Angina
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Myocardial Infarction
Assessment:
MI
Diagnostic evaluation:
ECG shows deep, wide Q wave,
elevated or depressed ST segment, T
wave inversion
Increased Cardiac Enzymes
Myocardial Infarction
Treatment:
CPR
1st action: ______________
CPR: ABC
A open airway
B - breaths
C - circulation
If ECG shows ventricular fibrillation,
defibrillate
Defibrillation: Clear, Energy setting
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DEFIBRILLATOR
Medications
MONA
Morphine- vasodilator, analgesic
onset of symptoms
Anti-coagulants (Heparin/ Coumadin)
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Myocardial Infarction
SAPHENOUS VEINS
CARDIAC ARRYTHMIAS
- Abnormal electrical conduction or
Electrocardiogram (ECG)
Cardiac Arrhythmias
AF- feeling faint, irregular pulse,
palpitations
Asystole- no pulse, BP, apnea,
cyanosis
VF- no pulse, no palpable BP,
apnea
VT- chest pain, diaphoresis,
dizziness, hypotension, weak pulse,
possible loss of consciousness
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ATRIAL DYSRHYTHMIAS
PAC
Ectopic Atrial
Beat
Atrial Tachycardia
Atrial Flutter
Atrial Fibrillation
150-250
250-350
>350
*VENTRICULAR DYSRHYTHMIAS
severely reduces diastolic filling &
CO
absence of
pulse and BP
PVC Ectopic Focus
Ventricular Tahcycardia 101-250
Ventricular Fibrillation Chaotic
Asystole No electrical activity
Ventricular
Fibrillation:
Ventricular fibrillation is seen in dying
hearts.
No true QRS complexes >> cardiac
perfusion & whole body perfusion
stopped.
Cardiopulmonary resuscitation (CPR)
and electrical defibrillation must be
performed STAT
CARDIAC ARRYTHMIAS
Treatment:
- Anti-arrythmics
Atrial- Quinidine
Ventricular- Lidocaine
Beta-blockers, Calcium channel blockers
synchronized cardioversion
CPR, defibrillation
ICD (Implanted cardiac defibrillator)
transcutaneous pacing
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*HEART BLOCK:
First Degree: Impulse
slow to go thru AV
node
Second Degree: Some
impulse go thru AV
node, some do not
Third Degree: No
impulse get thru AV
node
PACEMAKERS:
- Types: Fixed
Demand
- Check basal HR
- Avoid sources of
electricity
(microwave, CP)
- No contact sports
Pace maker
CONGESTION
Heart Failure
Occurs when the heart cant
Ride side
HF
Hepatomegaly
Edema
Ascites
Distended
jugular veins
Weight Gain
Fatigue
Left-side CHF
Dyspnea
Orthopnea
Cough
Crackles
Frothy sputum
Heart Failure
Assess CV status and VS to detect decreased
cardiac output
Assess respiratory status
Keep in semi-fowlers position
Administer medications to reduce fluids and
enhance cardiac functioning
Analgesics (Morphine sulfate for pulmonary
edema)
beta-blockers
diuretics (Furosemide)- Nursing considerations
inotropic agents (Digitalis-Digoxin; normal
level, SE, signs of toxicity)
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Heart Failure
Monitor I& O, labs and weight
Provide suctioning as needed,
Endocarditis
Prosthetic valves
Hancoc
Mitral
Mitral
Mitral
Hypertension
Asymptomatic
Elevated BP
Dizziness
Headache
L ventricular
hypertrophy
Cerebral ischemia
Renal failure
Visual disturbances
including blindness
Epistaxis
Diagnostic Elevation:
Increased BUN,
creatinine, Na and
cholesterol levels
Sustained BP
readings of 140/90
mm Hg
CXR show
cardiomegaly
ECG shows LVH
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Hypertension
Treatment:
ANTILIPEMIC AGENTS
Cholyestyramine (Questran)
Reduces absorption of fats from GI
Tract
Atorastatin (Lipitor)
Simvastatin (Zocor)
Lovastatin (Mevacor)
Check Liver enzymes
Nursing Management
Assess CV status and VS; Take an
average of 2 or more readings to
establish HTN
Assess neurologic disorders and
observe for changes that may
indicate an alteration in cerebral
perfusion (CVA)
Monitor I & O and weight
Maintain a quiet environment to
reduce stress
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Sample Question
A client with angina pectoris has a
Sample Question
Which of the following will not be included
Sample Question
Because a client with MI can develop left
Diagnostic Tests
Chest X-ray
Sputum examination
Thoracentesis
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Oxygen therapy
tracheobronchial suctioning
chest physiotherapy
incentive spirometry
closed chest drainage (thoracostomy
tube)
EPISTAXIS
Sample Question
The patient is experiencing epistaxis
Epistaxis
down
pressure over the soft tissue of the
nose
cold compress
Avoid nose blowing
nasal pack with neosynephrine (3-5
days)
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Sinusitis
Rest
increase fluid intake
hot wet packs
anti-infectives or antihistamines
Laryngitis
Inflammation and swelling of mucous
membrane of larynx
Cause: Infection, improper use of voice,
smoking
Manifestations:
Hoarse voice, throat irritation, dry, nonproductive cough
Treatment:
ATB
Stop smoking
Removal of cause
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Tonsillitis
Inflammation of the tonsils
Sore throat, difficulty or pain in swallowing,
fever
ATB, anti-pyretics, saline gargles
Surgery: Tonsillectomy
Post-op Care:
- HOB to 45 elevated to reduce edema
- Monitor for frequent swallowing
- Avoid carbonated and citrus juices- irritate the
incision
- Ice chips, small sips of cold fluid, popsicles (1 st
day)
- Soft foods on 2nd day
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TONSILITIS
COPD : Chronic
bronchitis
Persistent cough for at least a month
edema of the mucous membranes
hypersecretion of mucus
blue bloaters
fluid and cellular exudation
cigarette smoking is predisposing
factor
Bacterial infection
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COPD : Emphysema
Over distended and non functional
factor
Asthma
COPD
Assessment:
COPD
Use of accessory muscles for
breathing
Posturing (leaning forward)
Prolonged expiration
Pursed lip breathing
Diagnostic Exams:
CXR- congestion and hyperinflation
ABG- respiratory acidosis and
hypoxemia
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COPD
Treatment:
Nursing Management
Monitor VS and respiratory status.
Administer low flow O2 (24-28%).
Monitor pulse oximetry
Monitor CV status to detect
arrhythmias related to hypoxia
Encourage to drink plenty of fluids if
not contraindicated
Instruct in diaphragmatic or abdominal
and pursed lip breathing techniques
Suction if necessary to clear airway of
secretions
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COPD
Position in high fowlers position and
leaning forward to aid in breathing
Encourage small, frequent feedings to
prevent dyspnea
Encourage activity as tolerated to
prevent fatigue
Encourage to stop smoking
Avoid exposure to persons with
infections
Avoid allergens and pollution
Receive immunizations: influenza (flu
shot)
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Medications
- Bronchodilators- Salbutamol and
theophylline- Instruct on the use of
both oral and inhalant medications
- Steroids- to reduce inflammation
- Anti-leukotrienes
(montelukast- Singulair), mast cell
stabilizers (Cromolyn Na)
- Mucolytics- to thin secretions
- Expectorants- Guaifenesin
(Robitussin)
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Status asthmaticus
High-fowlers position
Monitor VS
Monitor respiratory status
Epinephrine/ Aminophylline IV
Emotional support
Complications of COPD
Cor pulmonale
Definition: right ventricular
hypertrophy, secondary to disease
of the lungs; may or may not be
accompanied by heart failure.
Pneumonia
Refers to bacterial, viral, parasitic or fungal
infection that causes inflammation of
alveolar spaces & increase in alveolar fluid.
Ventilations decreases as secretion thicken
The edema associated with inflammation
stiffens the lungs, decreases lung
compliance and vital capacity and causes
hypoxemia
Causes:
Aspiration (NGT feedings) , chemical
irritants, bacteria, viruses
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Assessment
- Chills, fever SOB, tachypnea,
accessory muscle use
- sputum (rusty, green or bloody
with pneumococcal pneumonia
and yellow green with
bronchopneumonia)
- crackles, rhonchi, pleural
friction rub on auscultation
- cough, malaise
- restlessness (hypoxia)
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Pneumonia
Diagnostic exam:
- CXR shows diffuse patches
throughout the lungs or
consolidation in a lobe
- Sputum culture identifies
the organism
Pneumonia
-
Treatment:
CPT, PD, IS
Diet: High CHON, high calorie (to offset
hypermetabolic state) , force fluids
Administer O2 and respiratory
treatments
Position in semi-fowlers position to
facilitate breathing and lung expansion
Change position frequently and
ambulate as tolerated to mobilize
secretions
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Pleural Effusion
Pleural effusion- excess of
fluid in the pleural space
Normally the pleural space
contains small amount of
extracellular fluid to
lubricate it- increased
production or inadequate
removal results in effusion
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Pleural Effusion
Assessment:
- Pleuritic chest pain that is
sharp and increases with
inspiration
- Dyspnea, decreased breath
sounds, fever, malaise
- Dry, non-productive cough
caused by bronchial irritation
or mediastinal shift to
unaffected side
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Pleural Effusion
Treatment:
- Thoracentesis
- Thoracotomy
-
Nursing Management:
Explain thoracentesis to patient.
Instruct to report difficulty breathing
during the procedure. May indicate
pneumothorax
Remind to breathe normally and to avoid
sudden movements such as coughing to
prevent improper placement of needle
Monitor breath sounds
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Pneumothorax
Pneumothorax- loss of negative intrapleural
pressure > increased intrathoracic pressure and
reduced vital capacity
Types:
- Spontaneous- rupture of a bleb (bullae)
- Open opening thru the chest wall allows air to flow
between pleural space and outside of the body
- Tension-buildup of air in pleural space that cant
escape
In all cases, there is decreased surface area for gas
exchange resulting to hypoxia and hypercapnia
Pneumothorax
Assessment:
Dyspnea, diminished or absent breath
sounds unilaterally
sharp pain that increases with exertion,
dullness on percussion
tracheal shift to unaffected side
(tension)
decreased chest expansion unilaterally,
diaphoresis, subcutaneous emphysema,
sucking sound with open chest wound
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Pneumothorax/ Hemothorax
Nursing Management:
Apply dressing over open chest wound
Position in high fowlers position
Prepare for chest tube placement until the
lung has fully expanded
Monitor for hypotension, tachycardia and
tachypnea
Assess for pain and medicate as ordered
Administer O2
Assist in turning, coughing, deep
breathing and IS to prevent atelectasis
and mobilize secretions
Monitor chest tube drainage system
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Chest Tubes
Returns negative pressure to intrapleural
space
Used to remove abnormal accumulations of
air and fluid from pleural space
Collection chamber drainage
Water seal chamber- tip of tube is
underwater allowing fluid and air to drain
and prevents air from entering the pleural
space
Water oscillates (moves up when patient
inhales and moves down as patient exhales)
Suction control chamber- gentle continuous
bubbling normal
UST COLLEGE OF NURSING
Nursing Management
- Monitor for drainage (amount,
-
color)
Keep tubes free of obstruction
Change position frequently
Do not strip or milk tubes
Maintain the drainage system
below chest level to maintain
water seal and prevent reflux
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15 CM (STRENGTH OF SUCTION)
-2CM (T.IMMERSION)
______
13 CM
15 CM
(PRESSURE APPLIED)
2 CM
Lung Cancer
Malignant tumor of the lungs
(primary/ metastatic)
Causes:
- Smoking, exposure to environmental
and occupational pollutants
Assessment:
Cough, dyspnea, hoarseness,
hemoptysis, chest pain, anorexia and
weight loss, weakness
- Pack year history- # of packs/day x #
years smoked
UST COLLEGE OF NURSING
Lung Cancer
Nursing Management:
Lung Cancer
Provide activity with rest periods
Radiation therapy
Chemotherapy
No PERCUSION AND VIBRATION IF
BRONCHOGENIC CA
Pneumonectomy
removal of the entire lung
reasons: CA, abscess
Post op: Dorsal recumbent of semiFowlers on AFFECTED SIDE
ROM to shoulder
NO CHEST TUBE
Lobectomy
removal of a lobe
reasons: TB or abscess
Post-op: Chest tube
Segmentectomy
removal of a lobe segment
reason: infection in localized area
post-op: chest tube
Wedge resection
removal of a small portion of the
lung tissue
reason: small localized area of
disease near the surface of the lung.
Post-op: chest tube
Tuberculosis
Airborne, infectious, communicable
disease
Poor nutrition, overworked,
overcrowded places with poor
ventilation, immunosuppressed
Assessment :
cough, hemoptysis, dyspnea, low
grade fever, night sweats, fatigue,
malaise, anorexia, weight loss
UST COLLEGE OF NURSING
Tuberculosis
Diagnostic exam:
Mantoux test, Sputum culture for AFB
Nursing management:
Standard airborne precautions
Diet high in CHO, CHON, B6, C and
calories
CPT, PD and IS
Provide negative pressure room to
prevent spread of infection
UST COLLEGE OF NURSING
TB Medications
- Administer medications (MDT)
- Rifampicin- reddish orange secretions
- INH- peripheral neuritis- paresthesia
Sample Questions
a. Decreased cough
b. Pain on inspiration
c.
Sample Questions
The nurse explains to the client
Sample Question
The nurse includes which information in
a.
b.
c.
d.
Sample Question
In assessing a client admitted with
Sample Question
A patient has a chest tube to underwater
Intracranial contents:
Brain 1200 cc space - 1400 g
CSF 150 cc space
- 75 cc
Blood 100 cc space - 75 cc
Meninges 50 cc space
INCREASED INTRACRANIAL
PRESSURE
Brain Tissue
CSF
(skull)
surrounded by bone
Blood
ICP
INCREASED INTRACRANIAL
PRESSURE
Pulse: decreased
Respiration: decreased & irregular
Widening Pulse Pressure; increased SYSTOLIC BP
120/70
135/60
CUSHINGS TRIAD
Projectile Vomiting; headache
Restlessness (EARLIEST); Lethargy
LOC (Level of Consciousness)
Pupils
; dilating; non reactive
ICP: > 15 mm Hg
Nursing management
Position - Semi-fowlers, 30-45
degrees
Oxygenation
Safety
Rest- keep environment quiet
Control fever; prevent shivering
(predisposes to seizures)
vasovagal responses
Control HPN
Restrict fluid intake- if IV, slow
infusion
pharmacotherapy
diuretics (mannitol, furosemide)
dexamethasone
anticonvulsants (diazepam, phenytoin,
phenobarbital)
Sample Question
A patient is admitted to the hospital with
Sample Question
When planning for the care of a
preceded by an aura?
A. jacksonian (focal)
B. petit mal (absence)
C. grand mal (tonic-clonic)
D. Myoclonus
Seizures
brain
Types
grand mal (tonic-clonic)
petit mal (absence or little sickness)
Jacksonian
Febrile
Status epilepticus one seizure after
the other
Epilepsy- chronic recurring seizure
UST COLLEGE OF NURSING
Diagnosis
- EEG
* NO MEDS EXCEPT Rx FOR 24-48 HRS
BEFORE TEST
* NORMAL MEALS BEFORE TEST
* HAIR SHAMPOO DAY BEFORE, NO
OILS, LOTION
* No caffeine or caffeine containing
products
- LP to rule out infectious cause
Seizures
3 phases
Nursing management
Health education :
medications taken regularly
Cerebrovascular Accidents
Stroke
Destruction of brain cells due to sudden
CVA
Maybe an ischemic
hemorrhagic
Causes :
thrombosis
embolism
hypertension
subarachnoid
hemorrhage
Stages of Development:
TIA
- warning sign of impending CVA
- brief neuro-deficit:
-last 30 sec to 24 hours with complete return
to normal
Stroke in Evolution
Progressive neuro impairment over a
HEMORRHAGIC
THROMBOTIC/
EMBOLIC
ONSET
SUDDEN
GRADUAL
Signs and
Symptoms
Severe HA
Nausea and vomiting
SX of meningeal irritation
Increased restlessness
Confusion
Early instability
handedness)
Interventions
Hemorrhagic
Ischemic
Control HTN:
Nipride
Control hemorrhage:
Vitamin K
Cerebral Vasodilators
Platelet Deaggregators
- Aspirin
Antithrombotics
- Anticoagulants
Thrombolytics: ALTEPLASE
* THERES ONLY A 3-HR
WINDOW FOR Tx
Nursing Management
Parkinsons Disease
Mask-like facies
drooling of saliva
dysphagia
Shuffling and propulsive gait
Stooped posture
diagnostic test : clinical observation
Nursing Management
contractures
Aspiration precautions
pharmacotherapy
anticholinergics (biperiden,
diphenhydramine)
dopaminergics (levodopa, carbidopa)
dopamine agonists(amantadine,
bromocriptine)
UST COLLEGE OF NURSING
Myasthenia Gravis
Autoimmune disorder
Lack of acetylcholine
Hyperactive thymus gland that destroys
acetylcholine receptors
signs
muscle weakness (including dysphagia
and dyspnea)
easy fatigability
ptosis and diplopia
Drooling
UST COLLEGE OF NURSING
Diagnostic test
Tensilon Test (Edrophonium Chloride
Test)
short acting acetylcholine (5-20mins)
Nursing management
Aspiration precautions
accident preventions
adequate ventilation
adequate rest periods
Medical Treatment
Pharmacologic therapy:
Cholinergic Drugs
pyridostigmine Bromide ( Mestinon )
Neostigmine Bromide ( Prostigmin )
Immunosupprresive drugs
Prednisone
Nursing Considerations:
Nursing Alert!
-Always give the medication on time
- myasthenia crisis and cholinergic crisis
- Same symptom: Extreme muscle
weakness
- To differentiate: _______________
- Have a standby antidote at the
bedside (Anti-cholinergic drug:
Atropine Sulfate)
UST COLLEGE OF NURSING
Sample Question
The nurse is aware that the teaching
Sample question
The nurse should explain to the client
a.
b.
c.
d.
MULTIPLE SCLEROSIS
Autoimmune
characterized by exacerbation and
signs
- diplopia, scotoma, blindness (optic nerve)
- muscle spasms
- paresthesia
- Dysphagia
Nursing Management
Eye patch for diplopia
force fluids
avoid hot baths
Plasmapheresis
Pharmacotherapy
muscle relaxants (baclofen)
glucocorticoids
prednisone
Autoimmune: Guillain-Barr
Syndrome
An autoimmune attack of the peripheral
nerve myelin
Resolves about a month after onset of
symptoms due to regeneration of
myelin sheath
Also known as: post-infectious
polyneuritis
GUILLAIN-BARRE SYNDROME
Ascending paralysis affecting peripheral
and cranial nerves.
Follows viral infection- ?? Autoimmune ??
Supportive Nursing Care
Airway
Range of Motion
Skin
Autoimmune: Guillain-Barr
Syndrome
Pituitary gland
anterior pituitary
Posterior pituitary
ADH : SIADH vs. Diabetes insipidus
ADH: Water retention
SIADH: CONGESTION- HTN, crackles,
dilutional hyponatremia
- remove tumor (hypophysectomy),
replace Na
management of D. insipidus
vasopressin replacement (desmopressin)
UST COLLEGE OF NURSING
Hyperpituitarism
caused by pituitary adenoma (tumor)
Usually excessive GH
Gigantism/ Acromegaly
Enlargement of existing bones/ internal
organs
(heart, liver, spleen)
managed by surgery (hypophysectomy),
radiation therapy and chemotherapy
Gigantism
Acromegaly
Gigantism-acromegaly
Thyroid gland
triiodothyronine (T3) and thyroxine (T4)
metabolism and growth; heat production
hyperthyroidism vs. hypothyroidism
diagnostic tests
Diarrhea
heat intolerance
amenorrhea
Exopthalmos
Thyroid storm-
Nursing management
Rest
diet : high calorie and high protein
Cool environment and cold fluids
promote safety
protect the eyes
replace fluid and electrolyte losses
pharmacotherapy
beta blockers
propanolol (inderal)
synthesis
propylthiouracil (PTU)- agranulocytosis
methimazole (Tapazole)
Ca-channel blockers- anti-hypertensives
THYROIDECTOMY
Post operative care
Semi-fowlers
Check dressing (back of neck)
Trach set (risk of resp. obstruction)
O2 for 48 hrs
Suction
Check for tetany >> laryngospasm (Ca
gluconate)
Ca at bedside
Check laryngeal nerve (hoarseness)
GOITER
COMMON PROBLEM:
RESPIRATORY OBSTRUCTION
>> UPRIGHT POSITION
Hypothyroidism (Myxedema)
reactions
expressionless face
anorexia and obesity
bradycardia
hyperlipidemia and atherosclerosis
cold intolerance
constipation
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Myxedema
Cretinism
Nursing management
water)
Androgens
steroids
- Causes: Adrenal gland / Pituitary gland
tumors
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Cushings Disease
- Steroids breaks down CHO- glucose
- Fat metabolism affected- adipose
CUSHINGS DISEASE
Addisons Disease
Signs
fatigue, muscle weakness
anorexia, nausea and vomiting with
weight loss
hypoglycemia
hypotension, weak pulse
Bronze pigmentation
Salt, sugar and sad
management
Hormone replacement therapy (GMA)
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Sample Questions
Which nursing diagnosis is most likely
Sample Questions
For which complication of
Sample Questions
A client with hypothyroidism is
Diabetes Mellitus
resistance
80- 120mg/dL- normal
FBS
HgbAic- assesses compliance to
medications- >7%
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Signs
hyperglycemia > glycosuria
polyuria, polydipsia and polyphagia
Fats utilized- ketones > metabolic acidosis
Ketoacidosis > Lungs compensate
Kussmauls respirations (increased rate and
depth)
Acetone (fruity odored breath)
Macroangiopathy- CAD, nephropathy
Microangiopathy- retinopathy
Neuropathy (damages nerves- prone to
diabetic foot ulcers)
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Nursing management
Diet
low calorie, high fiber diet
20% CHON 30% fats 50% CHO
activity
regular exercise pattern
maintenance of ideal body weight
Pharmacotherapy
Oral Hypoglycemic agents
Can only be used in Type II
Examples : Metformin
Insulin therapy (MEMORIZE ONSET AND
PEAK)
rapid acting- Humulin R
intermediate acting- Lente, Humulin N (NPH)
long acting Ultralente
Hypoglycemia
Signs
restlessness
hunger pangs, weakness, tremors, pallor
diaphoresis, cold clammy skin
blurred vision, slurred speech and
altered LOC
management
simple sugars p.o. (conscious)
D50% IV (unconscious, hospital)
glucagon SQ, IM (unconscious,
home)
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Sample Questions
When can the nurse expect a client
Trauma
Management:
- Immobilize (splint) the more you move
it, the more it will break
- Neck (cervical)- immobilize neck ASAP!
- Cervical collar- prevent injury to phrenic
nerve
- RICE (Rest, ICE, Compression, Elevation)
- Reduction
* Open- surgery to re-align the bone
* Close (casting/ traction)
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CAST CARE
Allow a wet cast
Monitor the
extremity for
circulatory
impairment
(5PsCompartment
syndrome)
signs of infection
Monitor for any
drainage on the cast
Instruct not to insert
anything in the cast
Instruct to keep the
cast clean and dry
Instruct to do
isometric exercises
isometric exercises
weights are
hanging freely
- Maintain
continuous
traction
- There should be a
countertraction
Sample Question
bed
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Bryants Traction
Cervical traction
Pelvic traction
Crutchfield tong
Measurement:
2 below axilla
6 front of foot
2 to the side of foot
elbow flexion (20 30 degrees)
Exercises to prepare for CW:
- hand muscle ex
- arm muscle ex
Gaits
Stair climbing:
UP: good leg >> crutches with bad
leg
Down: bad leg with crutches
>>good leg
CRUTCH WALKING:
Nursing Considerations:
- stand on the affected side
when
Cane held on
non-affected side
Cane walks
together with weak
leg
HIP FRACTURES
Common among elderly women
Total or partial hip replacement
Post-op care:
Rheumatoid Arthritis
systemic
Progressive, lifetime disorder
Synovitis and bony ankylosis
(permanent)
Can cause other systemic symptoms
Rheumatoid Arthritis
Management
Bed rest during acute pain
passive ROM exercises
splint painful joints
heat and cold applications
physical therapy
Warm shower in AM
Surgery
osteotomy, synovectomy or arthroplasty
Pharmacotherapy
Aspirin (anti-inflammatory)
NSAIDS
Ibuprofen (Motrin)
Corticosteroids
intra-articular injections
Osteoarthritis
rest
stiffening of the joints
Heberdens and Bouchards nodes
decreased ROM and crepitus
Normal
Degenerated
Management
relieve strain and further trauma to
joints
cane or walker if indicated
proper body mechanics
avoid excessive weight bearing and
standing
physical therapy
relief of pain (NSAIDS)
joint replacement as needed
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Gout
Disorder of purine metabolism
uric acid crystals in the joint: Tophi
signs
joint pain, redness, heat, swelling
unilateral with ears, ankle and great
Gout
Management
rest
Low purine diet and increase fluids
pharmacotherapy
Gouty Arthritis
roots
L4 and L5 most commonly affected
caused by heavy lifting,
degeneration of disc
Signs
cervical disc
-shoulder pain radiating to hand
- weakness
-Paresthesia
-sensory disturbance
Lumbosacral
Management
board
traction
local application of heat
lumbosacral corset (back brace)
prevent complications of immobility
Surgical management
Laminectomy with Discectomy
- Lamina of the vertebrae are removed
Surgical fusion (spinal fusion and rod
insertion)
- Insertion of metal plates and screws and/or
use of bone grafts
Post-op:
- Lumbar: HOB flat, supine with legs slightly
flexed
- Cervical: HOB elevated, with neck
immobilized with collar or sandbags
- Log rolling technique
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Smile!
Glaucoma
Increased IOP resulting from inadequate drainage
Open-Angle Glaucoma
Closed-Angle Glaucoma
medication
Avoid drugs that causes pupil dilation
Prepare for surgery
Glaucoma
Care: Routine post-op care
Eye patch
Position on back or on unoperative
side
Assess for signs of increased IOP
Meds: Steroids, Antibiotics and
Miotics (Pilocarpine)
Diuretics, beta-blockers, Epinephrine
(open angle)
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Cataracts
Opacity of the lens that distorts the image
Manifestations:
- painless blurring of vision
- pupillary color may change to yellow, gray
or white
- reduced visual acuity
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CATARACTS
TYPES OF CATARACT
SURGERY
CATARACT SURGERY
Cataracts
Elevate HOB 30-45 ; place on non
operative side
Avoid eye straining
Protect eye from injury by wearing an eye
shield
Avoid constipation (increase IOP)
Cataract glasses magnify and objects will
appear closer
Retinal detachment
- separation of the retina from the
Retinal Detachment
RETINAL DETACHMENT
- Separation of Retina from Choroid
Assessment:
Flashes of light
Blank areas of Vision
Floating particles (Veil-like cover of the field of vision)
Nursing Care
Preop
Bed rest; affected eye in
dependent position
Both eyes covered
Affected eye
Cycloplegics
Mydriatics
Post-op
Bed rest; flat/ low fowlers
Mydriatics
Antibiotics
Corticosteroids
No reading3 weeks
Eye patch
Surgery
a.Cryosurgery- supercooled probe
Scleral Buckling
Menieres Disease
Disease of the inner ear resulting
MENIERES DISEASE
Menieres Disease
Acute attack:
Lying down to minimize head movement and
avoiding sudden movements and reduce
dizziness
Anti-emetics and anti-histamines for n/v and
vertigo (Bonamine, Plasil, Benadryl)
Diuretics
Sodium restriction- reduce endolymph
Position: Recumbent with affected ear uppermost
Menieres disease
Surgical Interventions such as
SAMPLE QUESTIONS
a. hearing loss
b. pruritus
c. tinnitus
d. burning in the ear
GERD
Gastric contents flow upwards to esophagus
Common in obese and pregnant women
Any activity that increase intraabdominal
hernia
signs
GERD
Management
- Avoid alcohol, peppermint, caffeine,
reduced?
A. eat small frequent feedings and avoid
overeating
B. small evening meals with bedtime
snacks
C. belch frequently
D. swallow air
ulceration
maybe gastric or duodenal (most
common)
predisposing factors
Stress
Food (MILK included)
cigarette smoking and alcohol
caffeine
Drugs
H. pylori (90%)
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Peptic Ulcers
Manifestations:
Bloating, belching, n/v, pain (burning, gnawing
or aching) located in the upper abdomen and
occurring between mealtimes or at night,
pain associated with ingestion of specific
foods (spicy, fried, alcohol) and ASA, relief of
pain after administration of antacids and food
Diagnostics:
Barium swallow, fecal occult blood, Upper GI
series, endoscopy shows location of the ulcer
Gastric analysis: Normal gastric acidity in
gastric ulcers; increased in duodenal ulcers
NURSING MANAGEMENT
Relieve the pain
lifestyle modification
dietary modification
quit smoking
stress therapy
pharmacotherapy
antacids
Magnesium/ AlMgOH
Calcium/ aluminum
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Antibiotics
Amoxicillin
Metronidazole (Flagyl)
Surgery
Vagotomy- sever the vagus nerve- inhibits
release of HCl
Billroth I and II- gastric resections
Gastrectomy (Pernicious anemia)
TOTAL/SUBTOTAL GASTRECTOMY
Billroth I and Billroth II
Dumping Syndrome
Complication:
Nsg Management:
Diarrhea (3Ds)
dizziness
Diaphoresis
palpitations
APPENDICITIS
Obstruction of vermiform appendix
signs
acute abdominal pain (RLQ) McBurneys
point
Rovsings sign- pressing the left lower
quadrant will cause pain to the RLQ
anorexia, nausea and vomiting
rigid abdomen with guarding
rebound tenderness
elevated WBC count, fever
Sudden cessation of pain means rupture
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APPENDICITIS
Risk Factors:
- Men>women
- 10-30 years old
- constipation
- low fiber diet
NURSING MANAGEMENT
Bed rest
NPO
Do not give NARCOTICS initially - will
Crohns disease vs
Ulcerative Colitis
Autoimmune
Ileum and ascending
colon
Right lower quadrant
pain
Diarrhea
3-5 watery stools
mucoid stools with pus
Transmural involvement
Ileostomy
Steroids and Flagyl
Autoimmune
Rectosigmoid
Lower left quadrant
pain
Diarrhea
15-20 watery stools
bloody mucoid stools
with pus
Shallow ulcerations
Colostomy
Steroids and Flagyl
Ulcerative Colitis
Interventions:
Steroids, Flagyl, antidiarrheal
(Imodium, Psyllium and
antispasmodic agents),
low residue, lacto-free diet,
elemental type diet, TPN, monitor
weights, I&O, stool specimens
Avoid: milk & gas-formers,
nuts,wheat grains, raw fruits & vegs,
alcohol, caffeine-containing prods,
smoking
Ulcerative Colitis
SURGERY:
- Total Proctocolectomy w/ permanent ileostomycolon and rectum removed and anus is closed. The
terminal ileum is brought out of the abdominal wall
- Continent ileostomy or Kock pouch- a reservoir
or pouch is constructed from a loop of ileum
- with a flat stoma on the right side of the
abdomen
- Advantages:
a. no need to wear an external pouch
b. minimal skin problems
c. no flatus or leakage of stool
Colectomy with
ileostomy
Surgery
Proctocolectomy
Colorectal Cancer
malignancy of small or large intestine (most common)- low
Colorectal Cancer
Diagnostic Procedures;
- Abdominal and rectal exam, occult blood test, barium
enema, proctosigmoidoscopy and colonoscopy
- Elevated CEA
Interventions:
ATB, analgesics, antiemetics; chemotherapy; radiation
therapy
Small bowel resection- ileotransverse colostomy
Colonic resection and anastomosis; temporary colostomy
Nutritional support
Emotional support
Monitor for tumor re-occurrence
Monitor for perforation and obstruction
Colostomy Care:
Stoma Care
color: pinkish, reddish in
Single-Barrel Colostomy
Double-Barrel Colostomy
Liver Cirrhosis
-scaring of the liver; irreversible damage to the
liver
Causes:
a. Laennec (alcohol)
b. Post hepatitis- fibrosis
c. Biliary obstruction
d. Cardiac
ASCITES
Nursing Management:
Correct electrolyte imbalance
Reduction of ammonia formation- formed in
intestines by intestinal bacteria in protein
a. NGT suction
b. Neomycin sulfate, Lactulose
c. Protein restriction
d. Tap water enema
e. Potassium sparing diuretics
f. Paracentesis
Esophageal Varices
Nursing Management:
1. IV fluids
2. Anti-emetics
3.Blakemore- Sengstaken Tube (esophageal balloon
tamponade)
Nursing Interventions:
a. Keep a pair of scissors at bedside- in the
event of acute respiratory distress cut across tubing to
deflate balloon
b. deflate esophageal balloon for 5 minutes at
8-10 hrs interval to prevent necrosis
Nursing Management:
a.Pain control- demerol (drug of choice) Do not
give MORPHINE- causes spasm of the sphincter
of ODDI
b. Anticholinergic- atropine
c. ESWL Extracorporeal Shock Wave Lithotripsyshock waves used to disintegrate gallstones
d. Cholecystectomy
- OPEN monitor for respiratory distress
- LAPAROSCOPIC
9.
manipulated
position: low to SF
monitor dressing
clamp T-tube as ordered
IVFs and vitamin supplementation
deep breathing exercise
early ambulation
Fat free diet for 6 weeks
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Surgical interventions
Abdominal Cholecystectomy
Laparoscopic Cholecystectomy
T-TUBE
GENITOURINARY
DISORDERS
- urea (major)
- creatinine, phosphates
- sulfates, uric acid
Regulation of electrolytes
- sodium
- potassium
- ADH (vasopressin)
Control of blood pressure
- renin-angiotensin system
Regulation of RBC production
- erythropoeitin
Diagnostic tests
laboratory tests
routine urinalysis
creatinine clearance
blood studies : BUN (8-25mg/dL),
Serum Creatinine (0.6-1.3mg/dL),
creatinine clearance (85-135ml/min),
serum electrolytes
cystoscopy
abdominal X-ray (KUB)
SAMPLE QUESTION
After a cystoscopy, a patient is alarmed
RENAL FAILURE
Types
acute - sudden loss of renal function ;
reversible
chronic - gradual progressive and
irreversible loss of renal function
causes
pre-renal
renal
post-renal
ARF INTERVENTIONS
CRF INTERVENTIONS
Dialysis, monitor I&O, F&E
Kidney transplant
Low CHON diet- limit accumulation of
end products of CHON metabolism
Fluid restrictions
Antihypertensives, diuretics
Epogen- stimulate bone marrow to
produce RBCs
Antipruritics; good skin care
TYPES OF DIALYSIS
Nursing Responsibilities:
Monitor venous access site for bleeding
Dont use arm for BP, IVT or
venipuncture
Auscultate for bruits and palpate for
thrills
Weigh before and after the procedure
Monitor for shock and hypovolemia
Monitor for dysequilibrium syndrometoo fast removal of wastes- confusion,
weakness
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HEMODIALYSIS
PERITONEAL DIALYSIS
SAMPLE QUESTION
When teaching a client who has just started
SAMPLE QUESTIONS
During the oliguric stage of ARF, serum
potassium is usually:
a. normal
c. elevated
b. decreased d. absent
SAMPLE QUESTION
In caring for a client with hypovolemic
MANAGEMENT
C and S before antibiotic therapy
increase fluid intake
acidify the urine
perineal hygiene
regular bladder emptying
hot sitz bath
SAMPLE QUESTION
To help prevent recurring UTI, the nurse
UROLITHIASIS/
NEPHROLITHIASIS
- formation of stones in the urinary tract
Risk factors :
- diet high in calcium and protein
- Urinary stasis
- Dehydration
- Uric acid accumulation
- Prolonged immobility
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URINARY CALCULI
(UROLITHIASIS)
Types of stones
MANAGEMENT
Fluids
strain urine
encourage ambulation
pain control
Acid ash diet for Ca/phosphate stones
Alkaline ash- cystine and uric acid
stones
- Low purine diet for uric acid stones
surgery
Urolithotomy/ nephrolithotomy
(nephrostomy tube)
ESWL
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SAMPLE QUESTION
GLOMERULONEPHRITIS
Acute (children) vs. chronic
acute : post streptococcal infection-
common in children
chronic :gradual and progressive
destruction of glomeruli
signs
headache, weakness, fatigue
Peri-orbital edema (worse in AM) and
hypertension
nocturia
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MANAGEMENT
Bed rest
relief of edema
diet
fluid restrictions
Benign Prostatic
slow enlargement of the prostate gland- 40
Hypertrophy
BPH
Interventions:
- Administer Finasteride (Proscar)- reduce size of
prostate
- Terazosin- Hytrin- relax the muscles and promote
urination
- ATB
-
BPH
CBI (continous bladder irrigation) after
surgery to promote hemostasis and limit
clots that block the catheter
Nursing Care:
Set rate of infusion per MD order; usually
to keep drainage reddish pink
Maintain infusion continuously, observing
color, clarity and amount of drainage
Bladder spasms typical after TURP, notify
patient
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PROSTATE CANCER
slow malignant change in the prostate
gland that spreads by direct invasion of
surrounding tissue and can metastasize to
bony pelvis and spine
Elevated serum acid phosphatase and
serum PSA (prostate specific antigen) and
carcinoembryonic antigen (CEA)
Biopsy- reveals malignancy , MRI, CT
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PROSTATE CANCER
Interventions:
Radical prostatectomy
Radiation
Diethylstilbestrol (Estrogen)
Orchiectomy- limit production of
testosterone slowing the spread of the
disease
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NEOPLASTIC DISORDERS
Pathogenesis
cellular transformation and failure of
immune response
etiology
Viruses (HPV, Epstein Barr virus)
chemical carcinogens
Food preservatives
Hormones (estrogen, androgens)
Diagnostics
cytologic examination
biopsy
ultrasound
X-rays, CT Scans, MRI
laboratory tests
AFP, HCG, PSA, CEA
endoscopic examinations
Cancer prevention
Therapeutic Modalities
surgical interventions
preventive, diagnostic, curative, reconstructive, palliative
chemotherapy
radiation therapy
immunotherapy
bone marrow transplantation
CHEMOTHERAPY
Alkylating Drugs
Anti-metabolites
Antitumor Antibiotics
Vinca alkaloids
Hormones
Corticosteroids
integumentary
pruritus, urticaria, stomatitis, alopecia and
Hematopoetic
anemia, neutropenia, thrombocytopenia
genito-urinary
hemorrhagic cystitis and urine color
changes
maintain adequate fluids
RADIATION THERAPY
External vs. internal radiation
sealed vs. unsealed
side effects
skin reactions
infection
hemorrhage
fatigue
weight loss
inversely related.
*Visitors 6 ft. from source; off limits to <16
y.o. & pregnant women
Shielding lead shields, lead container &
long handled forceps are musts in pts unit.
- Precautionary measures for sealed &
unsealed
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Stomatitis
diarrhea
nausea and vomiting
headache
hair loss/ alopecia
cystitis
BREAST CANCER
Most common cancer in women
Risk factors:
Family history
Obesity
HTN
Exposure to radiation and carcinogens
Nulliparity
Lack of breastfeeding
Early menarche before 12, menopause
after 55
- 1st pregnancy after 30
- Use of estrogen
BREAST CANCER
Signs
breast mass
dimpling
peau de
orange
nipple
retraction
nipple
discharge
Painless, non-tender,
Breast asymmetry,
breast
obstruction of dermal
lymphatics
Management
lumpectomy
simple mastectomy
modified radical mastectomy
mastectomy (halstead)
lymphedema is a common
complication
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POST- OP CARE:
1. POSITION: Fowlers position or unaffected side with arm elevated
2. CARE OF WOUND DRAIN (JP drain )
3. DBCE
4. ARM PRECAUTIONS- DO NOT LIFT HEAVY OBJECTS, WEAR
ELASTIC BANDAGE, AVOID INJURY TO ARM
5. MONITOR FOR COMPLICATIONS: INFECTION, SWELLING,
ARM EDEMA (LYMPHEDEMA)
6. ASSIST WITH POST-MASTECTOMY EXERCISES- 5-10X EACH/
3X/DAY
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SAMPLE QUESTION
Which of the following is the priority