1 NCLEX REVIEW – GAPUZ REVIEW CENTER (31 JANUARY – 17 FEBRUARY 2005, PICC, City of Manila)
DAY 1 (31 JANUARY 05) STEPS IN PASSING
Have a Right Attitude THINK POSITIVELY … have a Fresh Start KNOW what YOU WANT and HOW TO GET IT OVERVIEW OF ESSENTIAL CONCEPT TRY OUT Focus assessment 7 habits of SUCCESSFUL EXAMINEE
MOSBY – growth and development LIPPINCOTT – care of the Elderly and Communicable Disease DIGOXIN – monitor the creatinine… “ the TV DOESN’T look good to me” (DIGOXIN TOXICITY – nausea/vomiting, abdl cramps) Olive = butter CK LDH
– normalize 1 – 3 days after MI - 10 – 14 days
ATRIAL FLUTTER – SAW TOOTH
PROCESS OF ELIMINATION
2 consider MASLOW’s H of NEEDS consider the COMPLICATION whether ACUTE ALWAYS prioritize CHRONIC ABCs SAFETY FIRST NSG PROCESS
–
MMR VACCINE – only vaccine for HIV pt. Pt on HEPARIN – APTT (N 30-40sec), therefore if INCREASE – bleeding
2. TODDLER – falls 3. SUPRATENTORIAL craniotomy – semi fowler’s position INFRATENTORIAL – flat in bed 4. 5.
SCATTER RUGS – osteoporosis pts. TRIAGE ; burns, open fx – “SHOCK”
Things NOT TO BE DELEGATED by RN: Assessment, Teachings, Evaluation
POISON - nursing action in order : #1 CALL poison control center # 2 MINIMIZE EXPOSURE of pt to poison – pull him/her away from the poison # 3 IDENTIFY the poison
Pt 50y/o and
GENTAMYCIN – s/e tinnitus, vertigo, ototoxicity, oliguria
Pt with Rocky Mountain Fever – exposure to dog ticks Lyme’s Dses – deer ticks
LITHIUM CARBONATE – for ELDERLY : N level NOT more than 1.0meq/L ADULT : N .5 – 1.2 meq/L HEPA B diet : low fat, increase CHON DOWN SYNDROME – large tongue – feeding problem – poor sucking (infants) SAFETY PRINCIPLE 1. when can a child USE ADULT SEAT BELT? - if the infant is 40 lbs and 40 inches in height seat belt location in car: BACK CENTER SEAT
- mammogram – once a year.
Pt with PKU – LOW PHENYLALAMINE DIET (NOT phenyl FREE). – therefore LOW CHON
PSYCHE PATIENTS 1. remember to stick to unit rules/policy – be consistent to pt. 2. encourage verbalization – “tel me how…..” 3. sound knowledge of cultural diversity seek help of interpreter 4. acknowledge pt feelings – “it seems….” “this must be difficult…..” 5. emphatize with your patients’s feelings “ I understand how you feel…..” CATARACT – CAUSES – aging and trauma MRSA (methicillin resistant staphyliccocus aureus) - USE GLOVES AND GOWN WHEN W/ PT
3 COMPLICATIONS: bubbling, breakage, blockage Nsg ALERT: TUBES 1. GROSHONG CATHETER HICKMAN BROVIAC
- 2 lumen - 3 lumen - 1 lumen
ALL requires Central Venous Access sites: cephalic, brachial, basilica and superior vena cava PURPOSE: For TPN Administration of Chemo Agents, Blood Products, Antibiotics COMPLICATION: Thrombosis and Bleeding 2. CHEST TUBES – Water Sealed Drainage Types: Anterior – w/c drains AIR Posterior - w/c drains FLUIDS Water Sealed Drainage : 1 bottle, 2 bottle and Three bottle system 1 BOTTLE emerge)
:
2 BOTTLE emerge),
:
3 bottle
:
3 – 5cm of only (length of tube to be
NORMAL : BUBBLING is N in the 3rd bottle – it indicates that suction is ADEQUATE (if no bubbling STOPS in the 3rd bottle, meaning – inadequate suction) ABNORMAL : if bubbling occurs at the 2nd bottle – indicates LEAKAGE – action, check sealed at air tight container and the pt and bottle connection. In case there BREAKAGE, have extra bottle and emerge tube ASAP to prevent entry of air and or may use forcep to clamp tube temporarily. If pt. ambulates, keep bottle LOWER than the patient. ABSENCE of OSCILLATION at the 2nd Bottle – indicates blockage TOWARDS THE BOTTLE - When MILKING the tubings. EMERGENCY EQUIPMETS AT BEDSIDE: xtra bottle,clamp, gauze 3. TRACHEOSTOMY TUBE to maintain patent airway for pt w/ neurological problems and musculoskeletal disorders. nursing care:
First bottle – drainage bottle (no tube 2nd bottle - long rod 3-5cm FREQUENTLY USED 1st bottle – drainage 2nd bottle – water sealed 3rd bottle – suction bottle control
1. Suctioning – 10-15seconds - if (+) bradycardia, STOP - if accidentally dislodge, insert obturator to keep it open 2. AVOID: water sports – swimming 3. In changing ties – insert new one first BEFORE REMOVING old tie.
4 4. Ribbon or ties @ side of the neck only to avoid pressure. 5. Before and After suctioning – hyperoxygenate the patient.
4. PTCA – enlarge the passageway for bloodflow. problem: spasms that lead to arrhythmia C-STENT (cardiac-stent) – alternative to PTCA Maintains patency of bld vessels Problem: dislodge IABP (Intra Aortic Balloon Pump) - for Cardiogenic Shock problem: thrombus formation, infection and arrhythmia
5. PENROSE DRAIN - wound drainage system - doctors the one who removes this. - remove gradually
6. NASO GASTRIC TUBE – stomach and intestine (duodenum) Types: Levine Tube – for stomach - 1 lumen, for lavage (cleaning) and gavage (feeding) Salem Sump – for stomach - 2 lumen (I for suctioning, I for lavage/gavage) - if pt (infant) is having enteric coated meds, request for change in form of meds
Miller Abbot – for intestinal (w/ mercury b4 injection) - 2 lumen (insert then inject the mercury)
Cantor – for intestinal - 1 lumen
Nursing Care for NGT: 1. tip of nose to earlobe to xyphoid process (for stomach) 2. tip of nose to earlobe to XP + 7-10 inches for intestinal NGT 3. accurate means to verify correct placement: ALWAYS consider Two checking criteria: ASPIRATION and Gurgling Sounds Report the following: If (-) or decrease drainage, (+) nausea and vomiting (+) abdml rigidity Characteristic of Gastric Residual: more than 50 mo and coffee ground. Before feeding check for placement.
7. GASTROSTOMY TUBE (GT) PEG both for NUTRITIONAL PURPOSES n/v
GT – incision (abdomen to stomach) for pt (+) lesion at esophagus nsg care : report s/s of infection, abdl cramps,
5 -
provide adequate skin care
PEG – incision at skin long term therapy
Characteristic of drainage – 2-3 days after surgery (bloody to pinkish) – NO NEED TO REPORT THIS – it is expected
8. T TUBE - to drain excess bile until hearing occurs - place drainage bag at the level of t-tube (obstruction of t-tube – there will be excess drainage)
11. SUPRAPUBIC CATHETER – for genito urinary problem - inserted directly at the bladder wall - check if properly anchored
500 ml – N drainage in 24hrs, if report ASAP.
12. URETHRAL CATHETER – to drain urine. - never clamp because it can only hold 4-8 ml of urine. - keep open to drain urine from kidney pelvis.
9. HEMOVAC JACKSON-PRATTS (JP) system pressure.
BOTH used as close wound drainage suction BOTH system function on the system of (-)
JP – compress the container before attaching to the drainage. WHEN TO EMPTY: when its usually 1/3 to ½ full then RECORD the amount.
10. THREE-WAY FOLEY absence of clot – effective
SENGSTAKEN BLAKEMORE TUBE 3 lumen ( for esophageal balloon, gastric balloon, for meds) for pt w/ esophageal varices balloon tamponade 48 hrs – keep balloon inflated for 10 minutes to decrease bleeding LINTON TUBE – 3 lumen MINESOTTA TUBE – 4 lumen SCISSORS – important EQUIPMENT AT BEDSIDE FOR ALL TUBES. HEMOSTAT – important instrument that shld be @ bedside for water sealed drainage. Persistent bubbling at water drainage bottle – for bottle #2 – check if tubing is properly sealed. NGT IS REMOVED – if patient exhibits return of bowel sounds.
6 BULB SYRINGE – use to clean the nares of pt with NGT (child) To facilitate removal of air at lungs – purpose of water sealed chamber in 3 way bottle system.
THERAPEUTIC DIET GENERAL CONSIDERATION Know the DIAGNOSIS of the patient Identify & incorporate the pt. dietary preferences Instruct pt on what to avoid For pregnant pt, note dietary changes: a. addtl calories (300 cal/day) average of 2400 2700 b. addtl of 10gms/day for CHON c. IRON : 15-30mg/day d. CALCIUM : RDA is 1000 then +200mg/day (broccoli,tuna,cheese) e. Galactogogues – increase production of milk
PEDIATRIC pt – by 4-6 mos – START iron supplement due to iron depletion and (-) extrusion reflex. cereals, fruits, vegetables,meat and table foods egg yolk (6mos), egg white (1yr)
TRANSCULTURAL CONSIDERATION CHINESE – like cold desserts after surgery for optimum health
JEWS – “kosher diet” (no meat and diary products at the same time) EUROPEANS – main meal is served at mid day followed by espresso
MUSLIM – “halal diet” – no pork
SDA – strictly vegs diet (vit B6 and B12 deficiency)
MORMONS – words of wisdom (no caffeine, alcohol and once a month fasting) – the amount due for food is donated to the church
KEY POINTS FOR NURSES Sodium (Na) – source down the soil Potassium (K) - source up the tree Low Na Diet : AVOID processed foods, milk products and salty foods KNOW the serving:
CHO - 6-11 servings CHON - 2-3 FRUITS & Vegs - 3-4 FATS - sparingly
MOST COMMON DIET CLEAR LIQUID DIET (light can pass thru it, meaning TRANSPARENT)
7 - given to pt to relieve thirst, correct fld & electrolyte imbalance - given also to pt post-op ex: apple juice, gelatin (strawberry), popsicle, candy
RENAL DIET
for kidney disorder (renal failure, AGN, Nephrotic syndrome) to maintain fld & e imbalance
LOW CHON – avoid poultry products LOW Na - avoid processed foods, milk products, & salty foods Low K - avoid fruits (anything you see in a tree)
PURINE RESTRICTED DIET
-
for gouty arthritis increase fluid intake AVOID: preserved foods, sea foods, alcohol, organ meat (liver, gizzard)
NA RESTRICTED DIET
salty foods
LOW FAT/CHOLESTEROL RESTRICTED DIET
for liver disorder, cardiovascular and renal dses ALLOWED: lean meat, fruits, vegs and fish AVOID : Sea foods, fried foods, preserved foods (cheese cake and custard) HIGH FIBER DIET to prevent constipation, hemorrhoids & diverticulitis vegs, fruits and grain products
for cardiovascular dses, renal, fld & e imbalance ALLOWED: fresh vegs AVOID : processed foods, milk products and
BLAND DIET
for peptic ulcer, inflammatory GI conditions AVOID: chemically and mechanically irritating foods such as fried foods, fresh and raw fruits & vegs (EXCEPT: avocado, banana & pinya) and spicy foods with preservatives
tissues
HIGH PROTEIN, HIGH CARBO DIET for burns (about 5000 cal/day) grain products and poultry – to aid the healing
SOFT DIET
for inflammatory conditions: esophagitis, peptic ulcer gastritis pureed foods/ blenderized foods soup
ACID ASH DIET
8 -
to decrease the ph of the urine indicated for pt w/ alkaline stone ex struvite ex. 3 C’S – cranberry, cheese, & corn 3 P’S - prunes, plums & pastries
Ph – 7.35 – 7.45 PCO2 - 35 – 35 HCO3 - 22 – 26 meq/L Ph
ALKALINE ASH DIET
to increase ph of the urine indicated for acid stone ( uric acid stone, cystine stone) ex. Milk -
GLUTEN-FREE DIET
PHENYLALANINE DIET
FULL LIQUID DIET
opaque transitional diet from liquid ex : cream soup, ice cream, milk, leche flan, pumpkin cake
“ABGs”
Uncompensated abnormal Partially compensated abnormal decrease Fully Compensated normal decrease
no change increase or increase or
Diarrhea – metabolic acidosis Vomiting – metabolic alkalosis
for celiac dses ALLOWED : rice, corn, cereals, soy beans AVOID (LIFETIME): barley, rye, oats, wheat
for PKU, until age 10 and adolescence only AVOID : CHON rich foods (meat products – luncheon meat)
Compensatory
Mechanism
ATERIAL BLOOD GASES
PRIORITIZING of case: Med.-Surg – “abc” Psyche - safety first Fire - race Triage - pt evaluation system (prioritizing)
APGAR SCORING
Appearance pink Pulse >100 Grimace vigorous
0
1
2
pallor
acrocyanosis
all
(-)
<100
(-)
grimace
9 Activity flaccid flexion & extension Respiratory (-) lusty cry
some flexion irregular
T.R.I.A.G.E -prioritizing
3. pt ask what procedure: Rn Action : notify the doctor 4. MI attack – 1st action : report ASAP (esp. presence of vent. Fibrillation) 5.
pt on NGT – check patency of tube
LEVEL 1 “emergency” severe shock, cardiac arrest, cervical spine injury, airway compromise, altered level of consciousness, multiple system trauma, eclampsia LEVEL 2 “urgent (stable)” can be delegated (fever, minor burns, lacerations, dizziness) LEVEL 3 chronic/ minor illness (can be delegated) – dental problems, routine medications and chronic low back pain
DELEGATION do not delegate Assessment, Teaching and Evaluation do not delegate meds preparation, administration, documentation CONCEPT OF DELEGATION consider the competence of personnel 5 R’s in delegating (RIGHT task, person, circumstances, direction/communication supervision) RN may delegate – feeding client, routine vital sign (pt w/ no complications) and hygiene care
TIPS ON PRIORITIZING 1. 2.
PT @ ER – sleeping pills overdose; pt bp 80/30 & mother died of CVA 1st priority : assess pt for addtl risk factor;
MI ATTACK – enzymes to increase IN ORDER #1 myoglobin #2 troponin #3 CK #4 LDH
10 RISK FOR INJURY – meniere’s dses INEFFECTIVE BREATHING PATTERN – myasthenia gravis ALTERED TISSUE PERFUSION – pt w/ complete heart block INEFFECTIVE AIRWAY CLEARANCE – pt w/ kussmaul’s breathing D
APPENDICITIS
Unruptured : any position of comfort Ruptured : semi to high fowler’s position to prevent the upward spread of infection complication: peritonitis Ruptured appendicitis indication: pain decreases or go away. (pt say, “I want to go home pain is gone”)
POSITIONING FOR SPECIFIC SURGICAL CONDITION Positioning – independent nsg function know the purpose of the position a. to prevent or promote soothing; b. what to prevent or promote; c. know your anatomy & physiology Post Liver Biopsy – R side lying – to prevent bleeding (during the procedure – L side lying).
BURNS
Position is FLAT or Modified Trendelenburg – to prevent shock. SHOCK occurs w/in 24-48hrs (immediate post burn phase). Complication: infection
Hiatal Hernia – upright to prevent reflux. AMPUTATION complication: hemorrhage (keep tourniquet @ bedside) 1st 24hr – goal: to decrease edema – elevate the stump at foot part w/ the use of pillow AFTER 24hr – goal : to prevent contracture deformity (keep leg extended)
CAST, EXTREMITY
Elevate the Extremity – to prevent edema (use rubber pillow) Nsg care: a. capillary refill – N 1-3 seconds only (complication: altered circulation) b. note for s/s of infection (when there is musty odor inside the cast) c. pruritus (inject air using bulb syringe) d. blood stained – mark and note (if increasing in diameter - report ASAP)
11 e.
tingling sensation – indicate nerve damage
HIATAL HERNIA
there is damage to esophageal mucosa what to prevent: gastric reflux therefore FEEP PT IN UPRIGHT POSITION.
CRANIOTOMY
Types: a. Supratentorial C – semi fowler’s orlow fowler’s position – to prevent accumulation of fluid at surgical site; b.
Position: to prevent subloxation (KEEP LEG ABDUCTED) with the use of wedge pillow or triangular pillow from perinium to the knees. dumping syndrome : “flat”
Infratentorial C - flat or supine. Purpose: same
HIP PROSTHESIS
FLAIL CHEST
(+) Traumatic Injury – paradoxical chest movement – areas of chest GOES IN inspiration and OUT on Expiration
LAMINECTOMY
STRAIGHT
“log-roll the patient” (3 nurses) – KEEP SPINE IN
ALIGNMENT AVOID: hyperflexion, hyperextension and prone – it causes hyperextension of the spine.
position: towards the affected side to stabilize the chest.
GASTRIC RESECTION
to prevent dumping syndrome – usually for 10 mos only NOT LIFETIME disorder (post gastrectomy) position : LIE FLAT for 1-2hrs post meal
LIVER BIOPSY
before LB : supine or L side lying to expose the part during LB : - doafter LB : R side lying w/ small pillow under the coastal margin to prevent bleeding.
12
LOBECTOMY
inside)
removal of Lobe (N R lobe – 3, L lobe – 2) position : semi fowler’s position – to promote lung expansion
MASTECTOMY
removal of breast elevate or extend affected arm to prevent lymp edema (or elevate higher that the level of the heart. AVOID: venipuncture, specimen taking, blood pressure – ON THE AFFECTED ARM coz there is no more lymph node w/c predispose pt to bleeding. Post mastectomy Exercises: squeezing exercises, finger wall climbing, flexionextension (folding of clothing, washing face, vacuuming the house) Due to removal of axillary lymph node, avoid also gardening and hand sewing
RESPIRATORY DISTRESS
Adult : Orthopneic position – over bed table then lean forward Pedia : TRIPOD – lean forward and stick out tongue to maximize the Airflow
RETINAL DETACHMENT
to prevent further detachment, place pt on the AFFECTED SIDE. Ex. If operation is on the R outer of the R eye, place pt on the R position. If operation is on the L inner of the R eye, position pt on the L side AVOID: sudden head movement.
PNEUMONECTOMY
either L or R lung. Position pt on the AFFECTED SIDE to promote lung expansion.
AVOIDE SEX (may burn penis bec of the implant
RADIUM IMPLANT OF THE CERVIX
dislodge.
keep pt on complete bed rest to prevent
VEIN STRIPPING
keep extremities extended then elevate the legs at level of the heart to promote venous return
TIPS liver biopsy is done on a pt. – during 1st 24hrs after the procedure, turn the pt on his abdomen w/ pillow under the subcoastal area;
13
a pt is about to go on thoracenthesis - how shld the nurse position the pt? – sitting w/ a arms resting on the overbed table;
1. DON’T ASK WHY – this put pt on the defensive 2. AVOID PASSING BACK – “I will refer you to….” 3. DON’T GIVE FAKE REASSURANCE – “everything will be alright….” “you’re in the hands of the best” 4. AVOID NURSE CENTERED RESPONSE – “I felt same too…” “I had the same feeling….”
to maintain the integrity of pt w/ hip prosthesis – abduction splints
In GROUP DISCUSSION – nurse is just a facilitator – let the group decide, he/she channel are concern back to the group.
immediately after supratentorial craniotomy- fowler’s position
THERAPEUTIC PHRASES – it seems… you seem…. - open ended question - close ended – for manic pt and pt in crisis - direct question- for suicidal pt
when draining the L lower lobe of the lung – the pt shld be positioned on his R side w/ hip higher or slightly higher than the head;
after tonsillectomy – position: prone
best position for pt in shock – supine w/ lower extremities elevated
THERAPEUTIC COMMUNICATION ISOLATION PRECAUTION RESPIRATORY OPTIONAL
OPTIONAL
Purpose : to isolate infection transmission (AIRBORNE: BEYOND 3FT DROPLET : W/IN 3FT) TYPE WASHING
GOWN
PRIVATE ROOM HAND GLOVE MASK
STRICT (airborne dses, direct contact-Diptheria)
TB OPTIONAL
OPTIONAL (negative airflow room)
14 CONTACT (direct contact – NOT AIRBORNE DSES) eX SCABIES ENTERIC X OPTIONAL OPTIONAL (fecal contamination) DISCHARGE
X OPTIONAL (drainage: pus ex burn pt) UNIVERSAL X (AIDS, HEPA b – TRANSMITTED BY BLD AND DODY FLUIDS)
\
OPTIONAL
TIPS: When implementing universal precaution, w/c nsg action require intervention: recapping the needle – this might prick your hand; When discarding the contents of the bed pan use by a pt under enteric precaution – GLOVE IS NECESSARY; A nurse is giving health teaching to the parents of child with scabies: family member must be treated; Preventing pediculosis in school age children: avoiding contact w/ hair articles of infected children like clips, head bands, hats – no sharing Patient with full blown AIDS is placed on isolation precaution – pt ask nurse why his visitors is wearing mask – response: it will help in the prevention of infection; Essential when a pt w/ meningitis is kept in isolation: isolation precaution remains until 24hrs after initiating antibiotic therapy
15 When local anesthesia used – NPO, 1- 2HRS AFTER General anesthesia – keep NPO at least 8hrd after (check gag reflex before meals) PEDIATRIC PATIENT – use flash cards, games and play to encourage participation
DIAGNOSTIC PROCEDURES side notes: pt for IVP : assess for allergy (cleansing enema b4 the procedure) pt for KUB : no dye (don’t assess for allergy) schilling test : 24hr urine specimen USG : no consent required GENERAL CONSIDERATION -
EXPLAIN the procedure to the pt (initial nsg action) if not ready inform the doctor; pt has the right to refuse procedure; doctor the one who asked for consent
WITH CONSENT
Check pt for CONSENT – if INVASIVE –
TRANSCULTURAL CONSIDERATION HISPANIC PATIENT – women prefer same gender health care provider Obtain help of interpreter when explaining procedures – (except or don’t ask family members) For muslim patient - they prefer same sex health care provider however, if procedures require life threatening – they prefer to have male doctor. - they only want good news information of their condition
NON INVASIVE – NO CONSENT needed
CONTRAST MEDIUM – check for allergy
For procedure requiring anesthesia – KEEP PT NPO B4 PROCEDURE
DELEGATION and DOCUMENTATION Delegation – assessment, monitoring and evaluation of treatment
16 (cannot be delegated) BUT standard and changing procedures can be delegated ex. – 24hr urine specimen and urine catheter collection.
monitor the baseline FHR then induce fetal movements by (HOW) :
Documentation – type of treatment and any untoward reactions.
then check FHR, NST is (+) if FHR increase at least 15 beats/min than the baseline. (ex. 140 FHB baseline, then after challenge it increase to 155)
KEYPOINTS FOR NURSES
Prepare the patient; Monitor for adverse reaction; Report complication to the doctor
FRAMEWORK – includes the Purpose, Special Consideration and Interpretation
DIAGNOSTIC TESTS (to evaluate FETAL GROWTH AND WELL-BEING)
DAILY FETAL MOVEMENT
Purpose : to determine fetal activity by counting fetal movements – usually perform by pt himself N Fetal Movement 10-12 for 12 hr period (average: 1 movement/hr with average 3fm/hr) NON STRESS TEST (NST) – correlates fetal heart rate w/ fetal movement
a. b.
ring a bell feed the patient
POSITIVE result means, BABY is REACTIVE (good condition) and no need for contraction stress test/oxytocin challenge test – coz baby is OK and doing well. CONTRACTION STRESS TEST (oxytocin challenge test) correlates FHR with uterine contractions pt on NPO get baseline FHR then induce uterine contraction HOW: Thru breast stimulation – it triggers the release of oxytocin from pituitary gland… If (-) patient is given Oxytocin – onset is 20-30 minutes. Then check FHR and note the presence of DECELERATION (slowing of FHR) types of deceleration a. early deceleration – indicates head compression (MIRROR IMAGE) b. late deceleration – indicates placental insufficiency (REVERSE MIRROR IMAGE) mgt: L Lateral Recumbent Position, Administer O2, Treat Hypotenson c. variable deceleration – due to cord (image: U or W shape) and slowing of FHR can occur anytime.
17 If (+) CST, meaning there is deceleration, baby is NOT OK coz there is decrease FHR and during labor he/she may stand the labor process.
AMNIOCENTESIS – AMNIO PERCUTANEOUS UMBILICAL CORD BLOOD SAMPLING – PUBS CVS PUBS
BIOPHYSICAL PROFILE
– CRITERIA
to determine fetal well being w/ the use of 5
fetal breathing movement heart tone reaction to NST amniotic fld volume
2 2 2 2 2
points points points points points 10 points
score below 6, indicates fetal jeopardy
AMNIO
Purpose: to detect chromosomal Purpose : same w/ CVS Purpose: to check chromosomal Aberration aberrations, & presence of RH (eg. Down syndrome, Trisomy 21) Incompatibility Done in 1st trimester can be done on the 2nd wk (14-16 wk) Extract blood at umbilical cord (can be done as early as 5th wk but - but not recommended bec. of danger then it is tested if it really comes can be done on 8-10th wk) abortion (assess pt age of gestation) from the umbilical cord (can be
ULTRASOUND done on either 2nd or 3rd tri.
- provide data on placenta (age and location) gender of baby structural abnormalities position of baby - for pregnant: site is lower abdominal USG types: a. b. -
Upper USG – NPO Lower USG - NPO preparation: increase fluid intake (oral) NO consent needed If pt ask if it is painful: NO PAIN; Pt shld have full bladder
or can be done on the 3rd wk (34-36 wk) purpose: to detect fetal maturity (FLM) Get sample at chorion (by 10-12wks – thru monitoring of L/S Ratio N 2:1 The placenta matures, get some sample) (if mother is (+) DM LS ratio is 3:1) This procedure also check level of alpha-feto Protein – if INCREASE – spina befida; If DECRTEASE – down syndrome
CHORIONIC VILLI SAMPLING – CVS
18 (+) Consent – invasive (+) Consent Bladder : Empty Gestation
(+) Consent
consider the Pt Age of
(if age of gestation : is higher than 20wks and above : empty bladder, if AOG is 20wks and below : full bladder
after amniocentesis w/c of the following manifestation if observed by the nurse on the patient that needs to be reported : bleeding; pt ask the nurse – what deceleration means – it refers to slowing of baby’s heart rate; USG DEVICE
before Amniocentesis, what to check –
COMPLICATIONS of CVS, AMNIO & PUBS: a. b. c. d.
infection bleeding abortion fetal death
TIPS EARLY DECELERATION – expected in the fetal monitor when there is fetal head compression; AMNIOCENTESIS – was done @ 35 wks gestation – purpose: to determine fetal lung maturity; A mother asked the nurse what will amniocentesis provide during pregnancy: it will show as whether the baby lungs are developed enough for the baby to be born; a nurse is preparing pt for lower abdl usg – w/c of the following done by the pt needs further teaching – pt voids b4 the procedure;
DIAGNOSTIC TESTS (to evaluate pediatric patients) CARDIOPNEUMOGRAM – use to diagnose apnea of infancy – assess HR, RR, nasal airflow and O2 saturation – N 95-98% below 85 – report ASAP GLUTEN CHALLENGE
19 detect presence of Celiac Disease (CD) intolerance to gluten; pt is given gluten rich food for 3-4 months the observe s/s of CD s/s of CD: distention
test for pre-teen : “bend over test” – bend and touch the toe; (+) scoliosis – if presence of rib hump, therefore x-ray then scoliometer.
abdl cramps, steatorrhea, abdl rigidity, abdl (if + for CD, gluten free diet will be for life time)
SICKLEDEX TEST ELECTROPOISIS
HGB
Purpose: test for sickle cell anemia Purpose: test for sickle cell anemia ORTOLANI’S TEST (OT) MANUEVER (BM)
BARLOW’S
purpose: test developmental dysplacia of the hip or purpose : same congenital hip dislocation
Specimen : Blood : (blood + solution, if (+) TURBID Specimen : Blood : bld + electropoiesis, if sickling of RBC Therefore TRAIT CARRIER (S or C shape RBC), therefore + for SC Dses Test for TRAIT
Test for Disease
(+) if w/ click sound (lateral) (+) barlow’s click – press downward and w/ click sound
POLYSOMNOGRAPHY or “sleep test” infancy -
EEG is connected to pt when he sleeps Check the brain waves, check for apnea of preparation : No Special prep, HOLD CAFFEINE FOOD – 2days b4 test
SCOLIOMETER -
measure the degree or angle of scoliosis check for: (+) scoliosis if uneven hemline uneven waist more prominent iliac rest and scapula on one side presence of rib hump
GUTHRIE CAPILLARY BLOOD TEST (GCBT) to detect PKU (in PKU there is absence of PHENYLALAMINE HYDROXYLASEPH)
20 Phenylalamine hydroxylase – is an enzyme that converts PH to Tyroxine – the one that gives color to hair, eyes and skin. If absent PH, no one will convert PH to Tyroxine, therefore it will accumulates to brain and can cause mental retardation. PH came from CHON rich food. At birth, it is usually negative, so give CHON food first for 3wks then retest. Before test, give chon rich food for 1-4 days before test. (adult) N PH level - >2mg/dl (if 4mg/dl – indicative of PKU, 8mg/dl – confirms PKU)
mother complains that her baby taste salty – which test is to be performed : sweat chloride test; 9 yo pt has (+) result for sweat test – this indicates possible dx of Cystic Fibrosis; pilocarpine – drug used for pt undergoing seat chloride test;
hgb electropoisis – test for sickle cell dses
SWEAT CHLORIDE TEST to detect Cystic Fibrosis (in CF, the skin becomes impermeable to Na. meaning cannot reabsorb Na and it accumulates outside of the skin); Mother complain that her baby taste salty; PILOCARPINE – used in the test to induce sweating; Types: a. sweat chloride test – N 10-35 meq/L (above 40 meq/L– (+) b. serum chloride test – N 90-110 meq/L (above 140 meq/L – (+)
DIAGNOSTIC PROCEDURES I.
CARDIOVASCULAR
A. ELECTROCARDIOGRAPHY – records the electrical activity of the HEART P wave – atrial depolarization QRS complex – ventricular depolarization ST - repolarization Rhythm – appearance of wave and distance Rate - N 60-100 bpm – check on # of QRS then divide it by 300 (k) ABNORMALITIES
TIPS
a.
pt w/ PKU would more likely to have (+) result in gluten capillary bld test if there is – adequate CHON in the diet;
atrial fibrillation – p waves “halos magkadikit. (no discernable p waves)
b.
atrial flutter – “saw tooth” flutter waves
21 c.
ventricular – check on QRS (N - .8-.12) D.
ANGINA – st segment elevation, t wave inversion MI - st segment elevation or depression, t wave inversion
CORONARY ARTERIOGRAPHY
medium -
visualization of the bld vessels w/ contrast nsg alert: (+)consent check allergy to contrast medium increase oral fluid intake after to excrete
dye B.
CARDIAC CATHETERIZATION
epinephrine shld be ready for any untoward reaction
heart -
it determine the structural abnormalities in the either L or R sided catheterization site: antecubital, femoral, brachial
common complications: embolism, bleeding, arrythimia “EBA” nsg mgt : monitor distal pulses (if brachial site: check @ radial if femoral site : check @ dorsalis pedis) if weak or no pulse – REPORT if (+) bleeding – report (“sandbag 10-20 lbs” – shld be at bedside)
C. stress -
STRESS TEST
E.
SWAN-GANZ CATHETERIZATION
4 lumen for the ff CVP, Pulmonary Capillary Wedge Pressure (PCWP), Pulmonary Artery Pressure, Bld products, Balloon CVP – measure R side pressure of the heart PCWP – L side of the heart N Pressure CVP: for R Atrium – 0-12 for SVC – 5-12 Nsg Alert : check pulse and s/s of bleeding
F.
BLOOD CHEMISTRIES
SODIUM (135 – 145 meq/L)
determines the ability of the heart to withstand equipment : threadmill & ECG nsg alert : check pulse and BP keep NPO an hr b4 the test NO Jewelries
Addison’s Dses: hyponatremia (dec Na), hyperkalemia (inc K) – “FLD IMBALANCE” Cushing Syndrome: hypernatremia, hypokalemia – “FLD VOL. EXCESS”
22
LDH (40 – 90 u/L)
POTASSIUM (3.5 – 5 meq/L) LDH1 – 27-37% (for heart – check for MI)
Hyperkalemia : Addison’s dses Hypokalemia : Cushing Syndrome LDH2 – 17-27% (for heart – check for MI) Inc or dec in K PT RISK of INJURY LDH3 – 8-15% (for respiratory system) Pt w/ digitalis & diuretics – monitor for arrhythmia LDH4 – 3-8% (for liver & kidney)
CALCIUM (4.5 – 5 meq/L or 9-10mg/dl)
Hyperthyroidism – inc CA Renal Calculi Formation – inc CA @ bld
LDH5 – 0-5% (for liver & kidney) LDH inc for MI for 3-4 days then it returns to N after 10-14 days
GLUCOSE (80-120)
CPK or CK
Higher than 140 – hyperglycemia (acidosis – may lead to ineffective breathing pattern and airway is the main problem)
Male – 12-70 u/L Female - 10-55 u/L
below 50 – hypoglycemia (pt prone to injury & altered thought process)
dyas
Increase CPK 3-6hrs post MI then it normalize 3-4
Creatinine (.5-1.5)
-
most sensitive index of kidney funx (increase BUN but N creatinine – do not report to AP)
disorder
-
increase creatinine – kidney failure or renal
BUN (10-20 mg/dl) inc. if (+) kidney disorder
AST (SGOT)
- N 8-20 u/L - for liver (inc. for liver dses) for cardiac dses)
G.
SGPT (ALT) N 8-20 u/L more on HEART (inc
HEMATOLOGIC STUDIES RBC (4.5 – 5.5 million)
23 - inc RBC – polycythemia – risk for injury – complication CVA - dec RBC – anemia – activity intolerance WBC (5-10 thousand) to detect presence of infection, bld disorders like leukemia dec WBC – pt prone to infection inc WBC – hyperleukocytosis – (+) to pt w/ leukemia – risk for infxn PLATELET (150,000-450,000) spontaneous bleeding occurs when platelet dec (pt also prone to injury)
DOPPLER USG to detect the patency of bld vessels – arteries & veins esp of lower extremities; painless, non invasive, NO SMOKING 30 min-1hr b4 the test PULSE OXIMETRY determines the O2 saturation at blood N 95-98 – attach to finger or earlobe (do not expose e light) II.
PT (11-12 sec) sec)
PTT (60-70 sec)
coumadin – check pt
heparin – PTT
monitor pt 4 bleeding
monitor pt 4 bleeding
APTT (30-40
HGB – male : 14-18 mg/dl Female : 12-16 mg/dl Dec hgb – anemia (nsg dx: activity intolerance) HCT - 35-45% - determine the adequacy of hydration and the ration of plasma to the cellular component blood inc hct : hemoconcentration (nsg dx: fld deficit – dehydrated pt) dec hct
: hemodilution fld excess
– – – – – SPUTUM) –
RESPIRATORY BRONCHOSCOPY visualization of b. tree or airway passages; to gather specimen for biopsy; NPO b4 & after Gag reflex return after 1-2hrs; Pt may expect a sore feeling (PINK STINGED Report (+) stridor CHEST X-RAY
to determine abnormalities of lungs and thoracic cavity; no preparation; ABSOLUTE CONTRAINDICATED TO PREGNANCY Check pt for radiation indicator Determine effectiveness of tx and whether pt is active or non-active
SPUTUM STUDIES
24 to determine the gross characteristic of the sputum (refers to the amount, color, abnormal particles, consistency and characteristic) TYPE OF SPUTUM PNEUMONIA TB
PROCEDURE: BREATH iN, HOLD
then EXHALE
- Viral – thin & watery Bacteria - rusty
BRONCHITIS - gelatinous
Sputum specimen – sterile container
THORACENTESIS - aspiration of fld at thoracic cavity (for diagnostic & therapeutic purpose)
position: DURING – sitting AFTER - affected or unaffected side Nsg alert: NO COUGHING & DEEP BREATHING – during the procedure – coz this may cause puncture of the lungs; Assess for breath sounds after; Complication: bleeding and pneumothorax
PULMONARY FUNCTION TEST
- thru the use of incentive spirometer - vital capacity (4-5 L of air) – refers 2 N amt of air that goes in & out of lung after maximum inspiration.
LUNG SCAN - to identify the presence of blockage in the pulmonary bld vessels; - with contrast medium; - (+) consent; - assess for rxn to allergy
- blood streaked
CHF/ PULMONARY EDEMA - pink stinged
EXHALE then INSERT mouth piece,
MANTOUX TEST - test for POSSIBLE TB EXPOSURE; - using PPD (purified chon derivatives) - angle 10-15, BEVEL UP then read 48-72hrs after
5mm in duration – (+) for HIV, multiple sex, previously (+) pt; 10mm - (+) for immigrants, children below 3yo and for pt w/ medical condition – DM & Alcoholism 15mm - (+) for general population
LUNG BIOPSY
- aspiration of tissues at lungs for dx of tumors, malignancy - assess for bleeding, breath sounds & report for s/s of dyspnea
25 CONTRAINDICATION III.
NERVOUS EEG
-
shampoo hair B4 (to remove chemicals) and AFTER to remove electrode gel (shampoo or acetone) measures electrical activity of the brain (gray matter) non invasive, (-) consent detect the ff: brain tumors, space occupying lessions alcohol brain waves and seizures
CONTRAINDICATION (same w/ ct scan BUT w/ addtl)
a. pregnancy; b. obese pt (more than 300 lbs); OBJECTS c. claustrophobia (give anti-anxiety b4) insulin pump, d. pt w/ unstable v/s (arrhythmic & HPN); hip replacement e. pt w/ allergy to dye “clicking sound” will be heard & procedure lie still lie still during the procedure sound” will be heard
NO METAL - jewelries, pacemaker,
lie still during the and “thumping
nursing alert: dietary modification: WITHOLD CAFFEINE – coffee and tea; WITHOLD 48hrs b4 the procedure : tranquilizers, sedatives, anti-convulsant, alcohol CT SCAN
MRI
PET
Use radiation to determine use electromagnetic field use gamma rays or positron electron tissue density to detect abnormality of tissue density to detect abnormality of tissue density; (detect cancer and tumor) also to detect O2 saturation @ tissue; physiology of psychosis; and to evaluate tx like CA Tx give more detailed impression (ex. Measurement of blocked artery) NSG ALERT: (w/ or w/out dye)
CEREBRAL ANGIOGRAM
involves visualization of bld vessels @ vein w/ the use of contrast medium. CONTRAINDICATED IN: pt w/ allergy; pregnant pt.; bleeding Nursing Alert: a. keep pt NPO; b. assess pt for allergy; c. monitor for signs of bldg; d. inc oral fld intake to excrete dye; e. keep epinephrine and or benadryl at bedside for emergency
26 -
N amount: 100-200 ml Characteristic : Clear w/ glucose, Na and H2O
If REDDISH – hemorrhage If Yellowish – infection Ear licking w/ fluid – test if (+) glucose bec. CSF has glucose.
LUMBAR PUNCTURE
MYELOGRAM
nucleus
test for presence of slip disc or herniated porposus (HNP).
ALERT: Know the type of dye use: aspiration of CSF for assessment to check for infection or hemorrhage
DURING : fetal or C-position : FLAT to prevent spinal headache
Needle is inserted between L3 and L4 or L4 and L5 Increase fluid intake after.
-
water based – called AMIPAQUE oil base – called PANTOPAQUE
type of dye will determine the position of pt AFTER the procedure.
position:
AFTER
a. b.
If water based, the HEAD OF BED ELEVATED; If oil based, FLAT after
Rationale for both oil and water based dye is TO PREVENT the upward dispersal of dye w/c can cause electrical meningitis (s/s includes: (+) seizure, headache)
CSF ANALYSIS Assess for the characteristic of CSF.
IV.
EENT
27 CONDUCTIVE HEARING
LOSS
TONOMETRY
-
to measure IOP (N 12-21) - painless but w/ local anesthesia ACUTE GLUACOMA : 50 yo and above CHRONIC GALUCOMA : 25 yo CALORIC STIMULATION TEST test the presence of Minierre’s Dses (inner ear) involves introduction of warm and cold water then NOTE FOR NYSTAGMUS – jerky lateral movement of the eye. SEVERE NYSTAGMUS – NORMAL MODERATE NYS - Minierre’s Dses NO NYSTAGMUS - Acoustic Neuroma -
GONIOSCOPY
V.
to differentiate OPEN and close angle galucoma; non-invasive, painless WEBER TEST
RINNE’S TEST
To determine lateralization of sound; To determine air and bone conduction If pt hears vibration better in GOOD EAR, Place tuning fork 2inches from the ear Problem would be SENSORINEURAL LOSS; place at mastoid bone or in teeth then…. if pt hear better in POOR EAR, - refers to if AIR CONDUCTION is LONGER, therefore CONDUCTIVE HEARING LOSS SENSORINEURAL HEARING LOSS; If BONE CONDUCTION IS LONGER, therefore
-
GASTRO INTESTINAL TRACT UPPER GI SERIES (Barium Swallow)
xray visualization with contrast medium - Contrast Medium:
a. Gastrografin – water soluble, use straw b. Barium - swallow – milk shake like (use feeding bottle of pt) - then pt is ask to assume different positions to distribute dye @ esophagus purpose: to detect disorders of esophagus feces : “chalky-white” after: instruct pt to take laxative to excrete dye
28 -
BARIUM ENEMA (for Lower GIT) involve rectal installation of barium;
-
ALERT: assess for allergy (epinephrine/benadryl)
Post procedure: inc. oral fld intake – to facilitate excretion of dye
there is balloon catheter inserted @ anus then barium is instilled and pt is asked to roll-over at different position then xray is taken to detect: hemorrhoids, diverculosis, polyps and lesions; after, give laxative to excrete dye (bec dye is constipating) instruct also patient to inc oral fld intake
GUAIAC TEST
to detect the presence of bleeding and inflammatory bowel condition like CANCER; specimen : stool (this can be refrigerated awaiting laboratory) AVOID the following 3 days B4 the test – bec it can yield to FALSE (+) RESULT : Red Meat, Fish and Horse Radish
CHOLANGIOGRAPHY
visualization of biliary tree (includes, hepatic duct & common bile duct) – same with CHOLECYSTOGRAPY – but medium given orally; -
with contrast medium w/s is given thru IV
GASTRIC ANALYSIS
analysis of gastric secretion like HYDROCHLORIC ACID Lower Level N : 2-5 meq/hr Upper Limit N: 10-20 meq/hr UPPER LIMIT YPES a. -
WITHOUT TUBE (tubeless gastric analysis) using DIAGNEX BLUE (specimen: urine); if urine colors turns BLUE, therefore (+) HCL Acid; if urine (-) blue color, therefore (-) HCL Acid
if (-) HCL Acid at stomach (achlorhydia), therefore Gastric CA; if Increase HCL Acid – therefore ZOLLINGERELLISON SYNDROME – (+) Gastric Tumor
29 b.
WITH TUBE – with the use of NGT then aspirate
-
Things to report: s/s of SHOCK – inc PR, dec BP Check v/s
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP)
ULTRASONOGRAPHY
upper abdl USG to detect abnormalities in the upper abdl area w/ includes biliary tree and Upper GI; painless; gel at abdomen and pt is NPO
LIVER BIOPSY
aspiration of sample tissue from the liver to detect: Hepatic CA and Cirrhosis; and
ALERT: Check for Bleeding Time (N – 1-9 mins)
Clotting Time (N – 10-12 mins) – because liver is highly vascular organ -
WHEN NEDDLE IS INSERTED tell pt to: Inhale then Exhale then Hold Breath – to stabilize liver position -
to visualize common bile duct and pancreatic duct; invasive – (+) consent; NPO – tube insertion; Tell pt that tere will be feeling of soreness a wk after the procedure
Position after : R side-lying position
COLONOSCOPY
visualization of colon to detect: inflammatory bowel condition Chron’s Dses Diverticulitis Hemmorhoids Tumor Polyps - (+) Consent - NPO b4
30 - clear liquid diet – 2days b4 the procedure position: Lateral or side lying position or L Lateral Sims
DEXAMETHASONE SUPRESSION TEST
to detect endogenous depression – depression resulting thru endocrine disorder pt is given dexa then 24hr urine specimen is collected; a dose of dexa will suppress the release of adrenal hormones; if despite dexa administration still increase adrenal hormones, therefore pt is suffering depression
VI.
ENDOCRINE GLUCOSE TOLERANCE TEST
test; midnoc);
17 KETOSTEROID & 170 HCS
use to detect the presence of Addison’s & Cushing’s Dses.
to provide measure of bld sugar level at blood; Inform pt to have high CHO diet 2 days b4 the
Addison’s – dec secretion of ketones Cushing’s – ince secretion of ketones
Instruct NPO a day b4 the test (npo post
Specimen: 24 hr urine
Inc sugar level, therefore Diabetes
ACTH STIMULATION TEST
to detect presence of Addison’s Dses specimen: blood pt is given dose of ACTH (not nore than 40ug/dl) if still dec despite ACTH administration, therefore Adrenal Insufficiency – Addison’s Dses
-
VANILLYLMANDELIC ACID TEST – VMA Test bi-product of CATHECHOLAMINE Metabolism epinephrine
norepinephrine
31 abnormality: inc if there is TUMOR (pheocromocytoma) of Adrenal Medulla
lower than 1.005 – diabetic insipidus higher than 1.030 – diabetic
mellitus (+) glucose – infection, DM (+) CHON - PIH, kidney dses.
N 2-7 mg/dl / 24hrs – if inc, therefore tumor Urine maybe refrigerated if waiting to be examined. AVOID: vanilla containing food 3 days b4 test – ice cream, coffee, chocolates
pt is given iodine 131 then after 24hr followed by a thyroid scan inc indicates hyperthyroidism, dec hypothyroidism AVOID: iodine rich-food (sea foods, sea shells, sea weeds) 7-10 days b4 and to include other diagnostic procedures that uses contrast medium (“NO” - angiogram test). – bec it may yield to false (-) result. SULKOWITCH’S TEST detect amount of calcium excreted at urine; if to test for hypercalcemia and hyperthyroidism - gather specimen b4 meals; to test for hypocalcemia and hypothyroidism – gather after meals VII. -
CULTURE & SENSITIVITY
RAIU
to detect infection prepare storage container KUB
IVP
- xray of the kidneys, ureter and bladder xray of the kidneys, ureter and bladder - NO SPECIAL PREPARATION NEEDED - uses contrast medium/ dye - assess for allergy, then inc. oral fld intake after - benadryl or epinephrine at bedside for allergic rxn - NPO POST MIDNOC, cleansing enema in AM
R E NA L URINALYSIS examine the gross characteristic of the urine
urine amount : 30-60ml/hr color : clear, amber s. gravity : 1.010 – 1.025
-
CYSTOSCOPY visualization of urinary bladder after : monitor I & O; note for s/s of bleeding
32
RENAL BIOPSY
detect: a. b. c.
aspiration of tissues at kidney for biopsy to
-
note for s/s of bleeding
malignancy/ Ca malignant HPN kidney disorder
to alternately contract and release the muscle as needle is inserted HOLD muscle relaxant b4 the test
aspiration of fluids at synovial space to detect abnormalities; check for order of analgesic; apply cold pack
CYSTOURETROGRAM to check the patency of the ureter and bladder; monitor I & O CYSTOMETROGRAM
to evaluate the sensory and motor funx of bladder; to check if bladder respond to distention after installation of flds; monitor I & O
VIII.
BONE SCAN
detect rate of bone destruction or bone resorption for pt w/ osteoporosis; lie still during the procedure; PAINLESS AND NON INVASIVE
MUSCULO-SKELETAL ELECTROMYOGRAPHY
-
ARTHROSCOPY
- visualization of joints - KEEP TORNIQUET, ICE PACK and ANALGESIC at bedside
IX.
ARTHROCENTESIS
to detect electrical activity of the muscle; (+) consent;
MISCELLANEOUS BONE MARROW BIOPSY
Leukemia)
to check abnormalities at the b. marrow (eg.
33 emergency
site : ILEAC REST (+) consent assess for bleeding sand bag at bedside (post procedure) – for use
SCHILLING’S TEST
specimen: 24hr urine test for VIT B12 deficiency; for pt w/ PERNICIOUS ANEMEIA; pt is given oral VIT B12 then urine is collected, then NOTE for RATE of EXCRETION of VIT B12 (N – less than 40%); eg. If 100mg Vit b was taken – 60mg shld retain at stomach and 40mg will be excreted.
URINE UROBILINOGEN
use to detect the rate of RBC DESTRUCTION in a hypotonic solution (RBC Lifespan: 120 days) if lifespan of RBC >120 days, therefore HEMOLYTIC ANEMIA (EX. SICKLE CELL)
detect presence of MULTIPLE MYELOMA (malignancy of plasma cells); RELEASED by destroyed or damage bones
HETEROPHIL ANTIBODY TEST
detect presence of IgM w/c is related to Epstein Virus infection Epstein Virus Infection – causative agent of infectious mononucleousis (“kissing dses”)
to detect HEMOLYTIC DSES WITHOLD ALL MEDS – 24hrs b4 the test BENCE-JONES PROTEIN
ERYTHROCYTE FRAGILITY TEST
mgt: AVOID SHARING of utensils and glass
LYMES DSES SEROLOGY
detect presence of BORRELIA BURGDORFERI – causative agent of lyme’s dses.
ROMBERG’S TEST
check FUNX of CEREBELLUM; stand erect, close eyes, and observe for inability to maintain posture (if pt is Swaying, therefore TUMOR at cerebellum)
Treatment: tetracycline
34 A pt is to have an upper GI series – which statement shows that he understood the instruction given : “I will drink the dye”. TIPS FOR DIAGNOSTIC PROCEDURE 2 moths old infant suspected of brocholitis is treated with oxygen therapy. Which result indicates that tx was effective : 02 SATURATION OF 98%. Pt is scheduled for liver biopsy. What shld the nurse instruct pt to do during needle insertion? - hold breath during the procedure upon insertion of the needle. Staff nurse is observing a nurse caring for pt w/ cvp. W/c action of the nurse require intervention? – touching the edge of the soiled dressing using clean gloves. Pt undergoing ERCP – important prep for nurse to make would be: keep pt NPO b4 the procedure. Pt w/ coronary angiogram, the catheter was inserted at the L femoral artery. w/c intervention is appropriate after the procedure: palpate the popliteal and pedal pulses. In explaining to the pt about cystoscopy the nurse shld say : the bladder lining will be visualize. A mantoux test is (+) – if the nurse assesses w/c of the following: in duration. w/c of the ff will yield an accurate reading of CVP: when the zero level of the manometer is at the level of R atrium. w/c responses made by the pt indicates that he understands the procedure to be done in a CT scan: “a dye will be injected to me”.
After liver biopsy, a potential complication: bleeding.
MRI is the primary diagnostic tool for multiple scelosis bec it promotes visualization of plaques at the brain.
35 LPN’s – peripheral IV Line route; ELDERLY PT – provide with memory aid PEDIATRIC PT – do not mix w/ milk (dosage depends on wt, age and size) For SIDE EFFECTS – GI symptoms (mostly) For AD. EFFECTS – always consider bone marrow (“leukocytopenia – all PENIA”) 3 COMMON DRUGS – with patients over 65 y/o a. LITHIUM – if above 65 yo, dose shld not more than 1.0mEq b. HALDOL – if above 65 yo, dose shld not more than 6mg/day c. MEPERIDINE – if above 65 yo, shld not 50 mg II. TRANSCULTURAL ASIANS – are stoicism attitude (they refuse meds if for the 1 time) st
MIDDLE EASTERNERS - they expect meds during first contact w/ hx care provider JEWISH – no meds restrictions JEHOVAH’S WITNESS – do -
ORIENTAL PAYLOAH (from mexico) treatment for diarrhea; may cause lead toxicity
-
ECHINECEA use to boost the immune system; for pt. with cancer
I. GENERAL CONSIDERATIONS
-
ST JOHN’S WORT anti-depressant (it funx like MAO inhibitor); do not give to pt taking MAO
ONLY RN’s are allowed to administer (to include central line)
-
VALERIAN sedative (used also as anti-anxiety agent)
DAY 5 (8 Feb 2005) PHARMACOLOGY
36 -
adverse effects – GI Irritation GINGCO BILOBA blood thinner; use to enhance bld circulation; for pt w/ alzeimers CONTRAINDICATED to pt with bleeding disorders
-
COMMON CONTRAINDICATIONS for HERBAL MEDS: liver
NO HERBAL MEDS for pregnant client; NO HERBAL to lactating pt; NO HERBAL for those with severe kidney and disorder
Lactulose – given to pt with hepatic enceph to dec ammonia absorption - s/e : diarrhea ANTABUSE (dizulfiram) – most appropriate time to take meds : after 12hrs of alcohol free. COGENTIN – to prevent pseudoparkinsonism (by decreasing muscle rigidity) TETRACYCLINE - can cause staining of teeth, Photosensitivity (use sunscreen when outdoors)
LITHIUM – shld have inc. fluid in the diet
III. DELEGATION AND DOCUMENTATION Document all medical admin record: time, route, dosage and untoward reaction; The following CANNOT be delegated: treatment, administration, documentation of meds
IV. C– HECK-
THE CHECK PRINCIPLE lassification (FOR WHAT?) ow will you know that he meds if effective (evaluation) xactly what time are you going to give it lient teaching tips eys to giving it safely
PSYCHOTROPIC I. ANTIPSYCHOTIC major tranquilizer; for SCHIZOPHRENIA (pt has EXCESS DOPAMINE); plays as treatment to the symptoms NOT CURE to schizo – meaning it modify the symptoms (target symptom: to decrease dopamine)
37 ex. Haldol Chlorpromazine Clozapine (chlozaril) Olanzapine (zyprexa) Risperdon BETS TO GIVE: after meals DOPAMINE – neurotransmitter (facilitate the transmission of neurons) In SCHIZO there in INCREASE NEUROTANSMITTER. Signs & Symptoms: a. DELUSION – “FALSE BELIEF” b. HALUCINATION - hearing sounds c. LOOSENES OF ASSOCIATION – shifting of topic
hyperpyrexia and muscle rigidity
this indicates NEUROLEPTIC MALIGNANT SYNDROME (NMS) drug of choice: Parlodel, Dantrium Assess SIGNS and SYMPTOMS of PSEUDOPARKINSONISM a. b. c.
mask-like face or expressionless face pill-rolling tremors cogwheel’s rigidity or lead pipe rigidity
AKATHESIA – “restless leg syndrome” (I feel as if I have ants in my pants)
DYSTONIA
Avoid direct sunlight – because meds photosensitivity
Instruct pt to rise slowly – to avoid orthostatic hypotension Check: CBC, BP, AST/ALT To prevent pseudoparkinsonism, administer ANTIPARKINSONIAN agents
IA. DOPAMINERGICS - ANTIPARKINSONIAN CLIENT TEACHINGS: – a. b. c. d.
Report ADVERSE EFFECTS of ANTI-PSYCHOTICS which indicates agranulocytosis fever body malaise sore throat chills
in schizo there is increase dopamine, therefore give antipsychotic to dec dopamine then dec dopamine causes pseudoparkinsonism. Therefore give dopaminergic. ex.
L-Dopa Levodopa Levodopa-Carbidopa
38 Effective if decrease in tremors and rigidity within 2-3 days; When to give: AFTER MEALS;
Health Teachings:
dietary modification: AVOID CHON and Vit B6 - bec it decreases drug absorption b. check for ORTHOSTATIC HYPOTENSION and PALPITATION; c. check BP and PR
b. c. d. e. f. g.
dry mouth – suck on ice chips or hard candy; palpitations – check PR; constipation – inc. roughage at diet; urinary retention NOT urinary frequency decrease BP – rise slowly check BP, PR, ECG
a.
II. ANTI-ANXIETY minor tranquilizer decrease Reticular Activity System – center of wakefulness ex. Valium, diazepam, Librium, Tranxene
Effective: Decrease Anxiety, Decrease Muscle Spasm (to pt w/ traction) Promote Sleep
B4 MEALS – because food delays absorption
HEALTH TEACHINGS:
a.
IB. ANTICHOLINERGIC -
decrease ACETYLCHOLINE
ex. Benadry Cogentin
effective: if decrease tremors and rigidity; when to give: AFTER MEALS;
Health Teachings:
a.
side effects: blurred vision (no driving);
report ADVERSE EFFECT: PARADOXICAL REACTION – opposite of side effects b. Danger of Dependency c. AVOID: Caffeine, Alcohol – it increase the depressant effect of the drug d. check RR – it causes respiratory depression e. administer VALIUM separately – because it is incompatible with any drug – use different syringe.
III. ANTI-DEPRESSANT/MANIC a. b. c.
TRICYCLICS MAO STIMULANTS
39 d.
SSRI
PATIENT with DEPRESSION – there is DECREASE norepinephrine and serotonin
40
A. TRICYCLICS – prevents the reabsorption of norepinephrine. Ex. Tofranil, Elavil Effective: If adequate sleep (8hrs only) Increase appetite
Avocado, banana, cheese (cheddar, aged and swiss) ALLOWED: cheese – cottage and cream, FRESH MEAT, VEGETABLES COLA, CHICKEN LIVER SOY SAUCE RED WINE PICKLES
Best given: AFTER MEALS Hx Teachings:
The INITIAL EFFECT 2-3 wks after FULL THERAPEUTIC EFFCET 3-4 wks ONSET EFFECT in a WK
AVOID : juice – because an acidic medium decrease absorption of drugs REPORT PALPITATION and TACHYCARDIA and ARRYTHMIAS – adverse effects of TRICYCLICS CHECK BP and ECG B.
Check BP – the drug can cause HYPERTENSIVE CRISIS – occipital headache – “my nape is aching” DEPRESSANT
2 WKS INTERVAL – when shifting ANTI – to avoid HYPERTENSIVE
CRISIS ex . after MAO – 2 wks rest then can give ST JOHN’S WORT
MAO INHIBITOR (MonoAmine Oxidase)
prevents the destruction of NEUROTRANSMITTERs ex. Parnate, Nardil and Marplan
C.
Effective : if INCREASE SLEEP and APPETITE –
STIMULANTS (Ritalin, Dexedrine and Cylert)
Give AFTER MEALS
-
Hx Teachings:
Effective: Increase Appetite and Adequate sleep
AVOID – TYRAMINE CONTAINING FOOD (1 day before FIRST DOSE and 14 days AFTER LAST DOSE)
Best to Give: AFTER MEALS if b4 meals, it suppresses the appetite; give NOT BEYOND 2pm bec. it causes INSOMNIA – 6 Hrs b4 bedtime;
directly stimulates the CNS.
41 INSOMNIA
shld be given in the morning – to avoid
N Na – 3 gms, N fluid intake 3L Basically, Lithium is a salt
COMPLICATIONS: growth suppression
provide intervals or intermittently to avoid growth suppression; check BP and PR
-
D.
Report also:
Hx Teachings:
SSRI (selective serotonin reuptake inhibitor) Ex. ZOLOFT, Prozac
Adverse effects: DECREASE LIBIDO and Impotence s/e: GI
Report the ff s/s (NAVDA) Nausea Anorexia Vomiting Diarrhea Abdl Cramps
FINE HAND TREMORS progressing to COARSE HAND TREMORS, THIRST and ATAXIC - sign of LITHIUM TOXICITY – Dug of choice: MANNITOL DIAMOX Hx Teachings:
III.1 ANTIMANIC
Lithium (lithane, lithobid, escalith) Tegretol Depakine/ Depakote
A. -
LITHIUM it alters level of neurotransmitters
effective if DECREASE HYPERACTIVITY give AFTER MEALS Hx Teachings:
diet: High Na (6-10 gms) and High Fluid (3-4L)
Avoid activity that increase perspiration – Na & H2o; Avoid caffeine; Monitor lithium level (specimen: blood drawn in the morning b4 breakfast or at least 12 hrs after the last dose) Frequency of Lithium monitoring: ONCE A MONTH; NORMAL LITHIUM LEVEL: ACUTE DOSE Below 65 yo mEq/L
MAINTENANCE DOSE .5 – 1.5 mEq/L
Above 65 yo .6 – 1.0 mEq/L
.5 – 1.2 .4 - .8 mEq/L
42 Lithium is effective with 10 – 14 DAYS before it will reach its therapeutic level.
Check :
CBC – due to pancytopenia RBC, WBC and Platelet label
CONTRAINDICATION OF LITHIUM:
Pregnancy; Lactating; Kidney disorder - if above s/s are (+) to patient, instead of lithium use TEGRETOL, DOPAKINE/ DEPAKOTE tegretol – a/e : alopecia
CHOLINESTERASE INHIBITORS For MYASTHENIA GRAVIS : Prostigmin (long acting) and Tensillon (short acting)
dopakine/ depakote - gingivitis
For ALZEIMER’s DSES Aricept
ANTICONVULSANT (Tegretol and dilantin)
Myasthenia Gravis – there is decrease or absence of Acethylcholine (ACTH)
for seizures, wherein there is abnormal discharge of impulse in the brain action : IT INHIBITS the seizure focus and discharge
ACTH is a neurotransmitter the delivers the order ex. Brain to muscle to contract/move.
effective: if (-) seizure given BEST AFTER MEALS (except for sedatives- like valium) – MOST DRUGS THAT AFFECT CNS ARE BEST GIVEN AFTER MEALS TOO. NSG ALERT: Report GINGIVITIS; Report S/S of Bone Marrow Depression – pancytopenia (dec RBC & WBC); Instruct pt to use SOFT BRISTTLED TOOTHBRUSH; Instruct pt to MASSAGE GUMS and frequent oral hygiene
: Cognex (tacrine) and
Therefore, the drug is given to inhibit cholinesterase in destroying ACTH (so, if dec cholinesterace and inc. ACTH, good muscle contraction) PROSTIGMIN – long acting – for treatment TENSILLON – short acting – only for 5 mins. – it increase muscle strength in 30 seconds (therefore, if muscle weakness disappear within 30 seconds – it is MYASTHENIA GRAVIS) Drug Action: Increase muscle strength (ex. Increase chewing ability or able to chew food forcefully) GIVE B4 MEALS or any activity;
43 Meds is FOR LIFE; Report s/s of HEPATOXICITY – RUQ pain of abdomen and JAUNDICE
“INR” – refers to the upper limit of meds from N value to the maximum dose
Antidote: ATSO4 – it reverses the effect of anticholinesterase Check for LIVER FUNX TEST; Keep at bedside: endotracheal tube – for resp. problem
ANTICOAGULANT HEPARIN LOVENOX
COUMADIN
For ACUTE CASES of Manic Case MAINTENANCE or Chronic CASE
FOR Heparin Derivatives
Antidote: PROTAMINE SO4 Antidote: VIT K Antidote same w/ Heparin Given SubQ (Lower Abdl Fat)
Oral Onset: 2-5 days
COAGULATION PROCESS: Vitamin K dependent clotting factors THROMBIN COUMADIN FIBRINOGEN
(maintenance case)
HEPARIN
Check PT (N 11-13 sec and INR 24 sec) Effective if (-) clot Give same time of day Report s/s of bleeding : Hemoptysis Hematemesis HEPARIN: AVOID – green leafy vegetables – bec it is rich in Vit K and will counteract the effect of anti coagulant. Therefore, diet of patient – no appropriate. NSG ALERT: monitor PTT (N 60-70 SEC, TIL INR of 175), if more than INR - HOLD
thromboplastin PRO THROMBIN
FIBRIN (CLOT)
COUMADIN – act as vit k dependent clotting factors HEPARIN – converts PROTHROMBIN to THROMBIN and FIBRINOGEN to FIBRIN - RAPID ACTING :onset : 24 – 48 hrs Coumadin and Heparin
44 – NOT to dissolve clot (only as THROMBOLYTIC – meaning it prevents ENLARGEMENT and FORMATION of CLOTS)
which causes arrhythmia. And so, to maintain the balance in the Na and K pump give antiarrythmia because it decreases the automaticity of the heart.
-
Antiarrythmia is effective if (-) arrhythmia;
can be given together
Give meds anytime; ANTIARRYTHIMICS Ex.
Quinidine (quinam)
Side notes: Health teachings: Characteristics of HEART MUSCLE: a. CONDUCTIVITY – ability to propagate impulses; b. AUTOMATICITY - ability of heart to initiate contraction; c. REFRACTORINESS – ability of t heart to respond to stimulus while in the state of contraction; d. EXCITTABILITY - ability of the heart to be stimulated Inotropic effect - force of contraction or strength of myocardial contraction; Chromotropic Effect – conduction of impulses; CHRONOTROPIC Effect - rate of contraction
a. report CNS – confusion, ataxia and headache GI - nausea, anorexia and vomiting b. RASH – therefore SKIN TEST FIRST c. REPORT s/s of QUINIDINE TOXICITY – tinnitus, hearing loss and visual disturbances d. check pt PR and ECG – waves, rate and rhythm QUINIDINE LIDOCAINE
PROCAINE
Ventricular arrythmia ANTIARRYTHMIC (quinidex, pronestyl) For VENTRICULLAR & ATRIAL Fibrillation
repolarization – resting phase (k goes out) depolarization – stimulating phase (Na goes in) (therefore the depolarization and repolarization of heart muscle depends on Na and K pump.) K – once it increase or decrease, it affects the repo and depo of heart muscle
CARDIAC GLYCOSIDES -
increase force of contraction;
45 affects the automaticity and excitability of the heart muscle; K – shld be monitored when in this meds therapy (The heart contraction is regulated by Na and K pump. If K decreases, Calcium enters and it will result to a more increase force of contraction due to Na and Ca pump conversion.)
Digitoxin – liver – AST/ ALT DIGIBIND – antidote for digoxin (lanoxin) THERAPEUTIC LEVEL: a. b.
Digoxin Digitoxin
: .5 – 2 ug/L : 14 – 26 ug/L
Effects: (+) INOTROPIC – strengthen the force of contraction (-) CHRONOTROPIC – decrease rate of contraction DIGOXIN
DIGITOXIN
EFFECTIVE : it increase FORCE OF CONTRACTION same ACTION mins – 2hrs
:
onset : 5 – 20 mins
Give after meals due to GI irritation same
CLIENT TEACHINGS:
Report s/s of TOXICITY : NAVDA Xanthopsia – yellowish vision or greenish halos;
Check PR – if BELOW 60/min (adult) – HOLD next dose; if BELOW 70/ min (older child) – HOLD; if BELOW 90- 110 (infants) – HOLD next dose
EXCRETION
Digoxin – kidney – monitor renal funx test (BUN & Crea) – report if inc;
NITRATES (nitroglycerine) 30
don’t give if pt taking VIAGRA – it will result to FETAL HYPOTENSION EFFECTS: dilatation of coronary arteries and arterioles thereby resulting to DECREASE IN PRELOAD & AFTERLOAD. Decrease in Preload – decrease in the amount of blood that goes to the LV; AFTERLOAD – amount of resistance offered by blood vessels that heart shld overcome when pumping blood Effective if NEGATIVE ANGINAL PAIN; Give BEFORE any activity; Administered SUBLINGUALLY (+ burning sensation indicates drug is potent) – NO WATER because it will dilute the meds; DOSES: 3 doses at 5mins interval; Report if there is persistence of pain; Check BP and PR; Keep meds in dark container (bec light dec potency);
46
Once the bottle is open, use the meds within 3-6 mos
DO NOT REPORT THE FF: (expected s/s) Hypotension, Headache, facial flushing “why is my face red?”
MUCOLYTICS (an antidote also for ACETAMINOPHEN TOXICITY) Ex. Mucomyst cola;
it decreases the viscosity of secretion; give meds anytime; client teaching: meds can be diluted w/ NSS or
Side effects: NAV + Rashes -
if no side effects, repeat dose in 1 hr
that required alertness (ex. Driving) ANTIBIOTICS bactericidal; effective: (-) infection; give ON EMPTY STOMACH – B4 MEALS; Hx teachings: REPORT rash, urticaria and “STRIDOR” – indicates airway obstruction; side effects: NAVDA + GI Irritation I. PENICILLIN : antidote is EPINIPHRINE II. AMINOGLYCOSIDE (gentamycin) effective: (-) infection – give B4 meals; report the ff: OTOTOXICITY: “I hear ringing in my ear” NEPHROTOXICITY : ”oliguria” NEUROTOXICITY : “seizures”
BRONCHODILATORS (ex. TERBUTALINE – brethine)
-
check BUN, CREA (kidney funx test); check I & O (sign of nephrotoxicity)
dilates the bronchioles or airways; effective: if (-) bronchospasm; GIVEN in AM to decrease insomnia REPORT THE FF: insomnia, tachycardia, palpitation-PR, + NAV
III.
ANTINEOPLASTIC (adriamycin)
CYSTITIS -
for breast and ovarian CA; effective: (-) tumor size; GIVE IN ARM – to prevent HEMMORRHAGIC
Theophylline - N 10-20; for ACUTE ATTACK and PREVENTION of ASTMA EXPECTORANT (robitussin) stimulates productive coughing; effective : (+) COUGHING & SECRETIONS give ANYTIME; sideffects: – NAV + DIZZINESS or drowsiness – avoid activity
a. prevention; b.
Hx Teachings: inc oral fluid intake (2-3L/day) – cytotoxic monitor kidney funx – I & O;
THYROID AGENTS (synthroid, cytomel)
47 for HYPOTHYROIDSM; effective: if Inc in T3 and T4 and NORMAL SLEEP; pt always sleep, therefore give meds in AM – to avoid insomnia; REPORT HE FOLLOWING: insomnia, nervousness; palpitations Take meds LIFETIME (same w/ meds 4 neuro); Check HR, PR and kidney funx test; ANTITHYROID -
(PTU, LUGOL’S SOLUTION)
For GRAVE’S DISEASE or HYPERTHYROIDISM; Effective: Decrease in T3 and T4 (in lab data); Give round the clock;
Health Teachings: a. Report sore throat, fever, chills, body malaise because meds cause AGRANULOCUYTOSIS; b. Report lethargy, bradycardia, and INCREASE SLEEP – indicates that pt is having HYPERTHYROIDISM; c. Diarrhea with metallic taste – sign of IODINE TOXICITY
b. monitor the blood sugar level in early AM and supper time INJECT AIR FIRST to NPH then inject air and WITHDRAW FIRST with REGULAR. PEAK OF ACTION (refers to – when patient becomes HYPOGLYCEMIA) REGUALR INSULIN Intermediate Long Acting
- lunch time - late in the afternoon – B4 dinner - B4 Breakfast
SULFONYLUREAS (Orinase) a. b. c. JUICE
for DM type 2; stimulate pancreas to produce insulin; effective – N bld sugar level; give b4 meals regularly; teachings: s/s of hypoglycemia; monitor renal funx test; antidote for hypoglycemia – ORANGE
ANTACIDS (amphogel, tagamet) ANTIDIABETICS (INSULIN) a.
effective: N Blood sugar (80-120) for DM Type 1 (insulin dependent); give in AM b4 meals; check: instruct S/S OF HYPOGLYCEMIA – dizziness/ drowsiness difficulty in problem solving decrease level of consciouness cold clammy skin
ALUMINUM HYDROXIDE GEL – antacid and it also dec phosphate level in pt renal failure; Effective: dec phosphate (-) pain - give on EMPTY STOMACH (1 hr b4 or 2hrs after meals); - instruct pt to REPORT: muscle weakness in lower extremities – indicates HYPOPHOSPATHEMIA administer with glass of water; check phosphate level and renal funx test; assess for constipation
48 a. b. c.
teachings: monitor for hypokalemia level and I & O; report muscle weakness; give K rich food – banana, orange THIAZIDE (diuril)
-
LAXATIVES (dulcolax) Colace Metamucil Dulcolax Lactulose dependency a. b. c. d. electrolytes e. dehydration
– stool softener - bulk forming - rapid acting - 15-30 mins
effective : (+) BM; give AT HS (if NOT diagnostic procedure); give AFTER MEALS –for dyspepsia; meds is given in short duration only because of teachings: be near or stay near CR; s/e: diarrhea; NO lactulose for pt w/ diarrhea; Causes hypokalemia – therefore check Increase fld intake – to avoid
DIURETICS Target Organs a. Diamox – exerts effect at Proximal Convuluted Tubules; b. Lasix – at Loop of Henle; c. Diuril – at Distant Con. Tubules
give in AM; monitor for hypokalemia; check I & O, K level, PR and BP K-SPARRING (triamterene, aldactone)
-
effective: inc. urine output; give in AM; teachings: monitor for HYPERKALEMIA check PR and K
ANTIGOUT PROBENECID ALLOPURINOL
- URICOSURIC - for ACUTE GOUT - for CHRONIC GOUT - promotes excretion of uric acid - has anti-inflammatory effect by - prevents or dec formation preventing deposition of u.acid of u. acid @ joints - s/effects: NAV + - NAV + Bldg and Bruising - dizziness/drowsiness Hypersensitivity agranulocytosis (check CBC) - ONSET: 8-12 wks ONSET: 1-3 wks
-
LOOP DIURETICS (lasix) effetctive: incrase urine output; give in morning to prevent nocturia;
COLCHICINE
TEACHINGS:
-
49 a. b.
Increase ORAL FLUID INTAKE; Monitor uric acid levels;
MIOTICS (timoptic, piloca) DECREASE IOP (N12-21) for pt w/ glaucoma; Give ANYTIME – but for LIFETIME; Teachings: a. it causes blurring of vision and brow pain; b. administer meds at lower conjunctival sac; c. press the inner canthus for 1-2 mins to prevent systemic side effects (hyperglycemia and hypotension) MYDRIATRIC (AK-Dilate) -
effective: pupillary dilatation; give ANYTIME (but if pt for surgery, give b4); teachings: may cause blurring of vision lower conjuctival sac
ANTI-ACNE (acutane, retin-a) pregnant; skin
decrease sebaceous gland size; given in AM to prevent insomnia; avoid sunlight: photosensitivity pregnancy: fetotoxic - therefore check if pt is check if pt has skin irritation – may burn the
TOCOLYTICS (Yutopar, MgSO4) a.
relax the uterus; drug of choice for pre-term labor; effective: (-) pre-term or relaxed uterus; give: ORAL – B4 meals and IV – anytime; teachings: signs of Ca Intoxication: hypotension, hypothermia and hypocalcemia b. check bld pressure; urine output (N 30ml/hr) c. check RR – at least 12/min d. check patellar reflex – shld be (+) knee jerk HOLD if RR – 10/min and urine output: 15ml/hr
CARBONIC ANHYDRASE INHIBITORS (diamox) Antidote: Calcium Gluconate for GALAUCOMA – lifetime; to decrease production of acqueous humor; effective: N IOP and Inc. urine output; effective to pt with MENIERE’S DSES – dec vertigo teachings: a. check urine output; b. report: s/s of dehydration bec of diuretic effect c. blurred vision d. monitor I & O and IOP
OXYTOXIC PITOCIN To induce labor prevent post partum hemorrhage Effective: Firm and Contracted Uterus Give anytime If IV, use “piggy back”
METHERGIN To
50 Teachings: a. REPORT the ff: HYPOTENSION (due to inactivation of ANS – neurological effect of drug); b. Headache c. Hypertension (cardiovascular effect of the drug) d. Check BP, Uterine Contraction – especially the duration – N 30-90 sec - report if beyond 90 sec – sign of uterine hypertonicity e. Check Force, Duration and Frequency of Uterine Contraction
TIPS ON PHARMACOLOGY Patient receiving DIAZEPAM, the nurse notice that there is no change in patient behavior. What shld the nurse do? – VERIFY THE PT DIET COGNEX – given with AZEIMERS’S DSES – to increase mental functioning
PROSTAGLANDIN (cytotec, E2gel)
effacement -
Pt w/ COMPLETE HEART BLOCK: give ATSO4 – it increases HR
anti ulcer drug to dec gastric acidity; decrease ripening of the cervix w/c leads to then dilatation then abortion; give after meals; assess for diarrhea and gastric irritation; check for pregnancy bec it may cause abortion
Pt w/ PVC : bedside : XYLOCAINE
Pt w/ DIVERTICULITIS (pt has diarrhea) – the ff meds were given: what meds the nurse shld question : LACTULOSE Morphine S04 given to pt with Pul. Edema – to decrease anxiety Pt ask the nurse on why she will take COUMADIN when shes already taking HEPARIN – Heparin is given for ACUTE CASES while Coumadin for maintenance Pt on CHEMOTHERAPY complains of nausea and vomiting, w/c meds can be given – ZOFRAN Expected side effects of STEROIDS : wt gain, obesity and Inc appetite Pt is taking LEVODOPA – observe for URINARY RETENTION
ADREAMYCIN – causes hemorrhagic cystitis
DESMOPRESSIN ACETATE – administered INTRANASALLY
51
DIARRHEA (enteric) yes x x
FESO4 – shld be given w/ orange juice
ASPIRIN I s given to pt w/ TIA – to decrease platelet aggregation
Pt taking ANCEF – observe for skin rashes
Pt to receive NPH at 7:30am, the nurse shld expect for hypoglycemia – LATE in the AFTERNOON
HEPA A (enteric) yes x
yes
C (universal) yes
yes
GW M AIDS (universal) yes
yes
x
yes
GL yes
x
yes
x
yes
yes
x
yes
yes
yes
yes
yes
MENINGITIS/SEPTIC (enteric) yes x x
x
SCABIES (contact) yes yes
yes
yes
TB (tb Precaution) x yes
yes
yes
PEDICULOSIS (contact) yes yes yes
yes
yes
TYPES OF PRECAUTION H
yes
x
B (universal) yes
MRSA (contacts) yes yes
P
x
P – private room H – handwashing GL - gloves GW – gown M - mask AIDS – universal
yes
yes x
52 Norwalk Virus – respiratory Hepa A – contact MRSA – contact Scabies – contact
The disorders result as alteration in the function of HEART (pump), BLOOD (transport mechanism of oxygen, nutrients, hormones & CO2) and BLOOD VESSELS (passageway).
PEDIATRIC CONSIDERATION a. all factors necessary for appropriate cardiovascular functioning are present at birth EXCEPT VIT. K (w/c is produced by intestinal mucosa); b. there are structures which are present at birth that may alter the route of blood circulation (present at birth: foramen ovale, ductus arteriosus, ductus venosus) c. note the CARDIAC RATE of pediatric pt (minimum $ y. children – 90-110, older c. – 70) REPORTABLE S/S FOR ADULT Palpitation, Pain and Paroxysmal Nocturnal Dyspnea For pediatric patient: observe for PALLOR – if (+) indicates ANEMIA for baby Day 6 (Feb 9, 05)
Nocturnal dyspnea – diff. of breathing at night Paroxysmal ND – when pt feels as if he’s
D.I.S.E.A.S.E.S (MEDICAL-SURGICAL NURSING)
drowning HEART SOUNDS:
GENERAL CONSIDERATION
S1 - normal – “lubb” S2 - -do- “dub”
-
Priority: Oxygenation
in assessing S1 & S2 use BELL of steth
53 S3 - N for Pediatric pt (ABNORMAL for adult pt – it indicates CHF or Aortic Stenosis) Steth - BELL – for LOW PITCH SOUND (ex. Murmur) Diaphragm – for HIGH PITCH SOUND
c.
Tachycardia and Tachypnea
Patient in shock- there is also (+) pallor and (+) oliguria – due to dec bld circulation & narrowing of bld vessels Lab Data (to check bld HEMATOCRIT (N-35-45%)
volume
circulation) -
–
check
check Urine
Output - check CVP Nsg Dx: FLD VOLUME DEFICIT rel to dec in Circ Vol. Priority Intervention: Fld replacement (D5Lr, NSS. Bld Trans – for jehova’s use plasma expander) SHOCK ANEMIA mp: decrease in circulating blood volume MP: Decrease RBC due to decrease production or increase destruction TYPES Risk Factors: CARDIOGENIC – pump failure (CHF, MI, Atherosclerosis Heart Dses, Mitral Valve Dses) HYPOVOLEMIC - related to fluid loss (pt w/ open wound, traumatic injury, burn) ANAPHYLACTIC cause by allergic reaction (laB procedure w/ dye, asthma, poison) NEUROGENIC - caused by vasomotor collapse (vasomotor – located @ medulla oblongata w/c is responsible for dilatation & constriction of bld vessels) SEPTIC – due to systemic infection (ex. Septicemia) TRIAD SYMPTOMS OF SHOCK a. Altered level of consciousness (dec bld circulation – result to dec o2 in the brain); b. Hypotension;
Age Gender Surgery Secondary to existing medical condition (ex. Renal Failure) Kidney – produce erythropoiten that stimulates bone marrow to produce RBC TYPES: a. b. c. d. e. f.
Iron Deficiency Anemia (IDA) Pernicious Anemia (PA) Folic Acid Deficiency Anemia (FADA) Sickle Cell Anemia (SCA) Aplastic/ Fanconis Anemia (AA) Talasemia Anemia (TA)
54 (for Z track IM – PULL SKIN LATERALLY, deep IM, wait 10 seconds before pulling the needle) FeSO4 – evaluate AFTER 4 weeks to check the effect IRON DEFICIENCY ANEMIA (milk
b. Diet: iron rich food – (organ meat, dried foods, “egg yolk” – iron, “egg white” – CHON); c. provide patient with BED REST – due to fatigue
common in infants and children; characteristic of patient: chubby but pale they are also called “milk babies” those baby 5 yo but still taking milk are poor source of iron)
PERNICIOUS ANEMIA
MP: Nutritional Deficiency
-
S/S : Fatigue Fainting Forgetfulness Pallor, cold clammy skin Dyspnea (due to dec RBC)
common in elderly; common in POST GATRIC SURGERY
Main Problem: Lack of INTRINSIC FACTOR at the stomach (intrinsic factor – the one that absorb vit b12) In elderly, there is that GASTRIC ATROPHY w/c leads to dec in the Intrinsic factor
Lab data: Decrease in HgB (N male: 14-18, Female: 1216) Characteristic
of
RBC:
HYPOCHROMIC
&
MICROCYTIC Nsg Dx: Activity Intolerance
S/S: 3F (fatigue, fainting, forgetfulness) Beefy Red Tongue or glossitis Peripheral Neuropathy (tingling sensation at lower extremities – usually both legs are affected)
Priority Intervention: a. Correct the deficiency – by administering iron supplements, - IRON RDA – 15-30 mgs/ day eg.
Oral FeSO4 (take w/ orange juice) if ELIXIR – use straw to avoid staining of
Lab Data:
teeth if IM (inferon) – “Z” track method
a. b.
check Hgb SCHILLING’S TEST (24hr urine)
55 c.
RBC characteristic : MACROCYTIC & HYPERCHROMIC
Nsg Dx: Activity Intolerance Risk for Injury due to p. neuropathy
presence of “S or C” shape Hgb due to dec O2 (SICKLING OF RBC) STATUS TRANS
N
TRAIT TRANS
DSES
Priority Intervention: a. Correct the deficiency – give Vit B12 (IM, Once a month for lifetime); b. Bed rest – due to fatigue
FOLIC ACID DEFICIENCY ANEMIA common in infants, adolescents, pregnant, lactating and overcooked food; Main Problem: Deficiency in Folic Acid or VIT B9 or FOLACIN S/S: all symptoms of pernicious anemia EXCEPT P. NEUROPATHY Lab Data: HgB Folic Acid level (N 4mg/day) – green leafy veg. (spinach) Nsg Dx: Activity Intolerance (NO RISK FOR INJURY coz NO P. NEUROPATHY) PI:
Inc. folic acid in the diet – g. leafy; Bed Rest
SICKLE CELL ANEMIA -
autosomal recessive hereditary
1 PARENT W/ TRAIT 0 BOTH PARENTS w/ TRAIT 25% I parent TRAIT, 1 DSES 50% BOTH parents w/ Disease 100%
50%
50%
25%
50%
0
50%
0
0
Risk Factors: Dehydration (dec in circ bld volume – result in sickling of RBC); Infections Conditions that lead to SHOCK S/S: 3Fs + Fever (due to dehydration) + Pain + Jaundice Hepatomegally
Complications: a. Vasocclusive Crisis (hallmark of the dses) - bld vessels obstruction by rigid and tangled cells w/c causes tissue anoxia and possible necrosis b. Spleenic Sequestration Crisis – massive entrapment of red cells in the spleen & liver c. Aplastic/ Megaloblastic Crisis – bone marrow depression w/c resulted to DEC RBC, WBC & PLATELET
56 Lab Data: Sickledex Test (+) Turbid Solution
MP:
Hereditary Autosomal Dominant – common in female and
male Nsg Dx:
PI:
Activity Intolerance Fld Volume Deficit Pain – due to vasocclusive crisis
There is a defect in polypeptide Chain of HgB – ALPA and ETA Chain – there is RBC destruction
Hydration and relief of pain (inc oral fld intake) Prevent dehydration Meds for Pain – Morphine SO4, acetaminophen Since HEREDITARY – refer to geniticist
APLASTIC ANEMIA
Types:
MP: Hereditary (there is DECREASE IN RBC, WBC & PLATELET) Autosomal Recessive
a. Minor Thalasemia Anemia – mild anemia: 3Fs b. Intermedia TA – more severe anemia + Speenomegally Jaundice (inc deposition of iron @ tissue) Hemosidorosis
S/S: 3Fs + Pallor + Dyspnea Risk for Infection (dec in RBC) Bleeding (dec in Platelet)
c. Major TA – severe anemia + Spleenomegally Lab Data: HgB, CBC, Clotting Factors Platelet, Bleeding & Clotting time Nsg Dx:
Lab Data:
Activity Intolerance (dec in RBC) Risk for Injury (dec in WBC and Platelet)
PI: Bld transfusion; Reverse Isolation; Genetic Counseling; Bed rest
HgB Clotting and Bleeding Time Nsg Dx:
Activity Intolerance Risk for Injury
PI :
Bld Transfusion, IVF Dietary supplements of Folic Acid and Iron Surgery (last resort)
THALASEMIA Risk Factors: Common Chinese, Indians
in
Blacks,
Italian,
Greeks,
LEUKEMIA
57 MP: proliferation of immature WBC
unknown (viral and autoimmune)
Characterized by Remission and Exacerbation
s/s:
Types: a. LYMPHOCYTIC – common in young children (proliferation of lymphocytes) b. MYELOGENOUS – adolescent and adult (proliferation of granulocytes)
lab data: Platelet Count of less than (spontaneous bldg) (N 150,000 – 450,000)
TRAID S/S:
petechiae ecchymosis hemorrhage (all signs of bleeding) 20,000
Nsg Dx: Risk for Injury Fld Vol. Deficit (due to bldg)
Anemia (initial) + 3Fs Bleeding Infection
PI :
Lab Data:
SAFETY –prevent bleeding Give pt platelet, IVF and Bld Transfusion Corticosteroids – “wonder drugs”
WBC – hyperleukocytosis (150 – 500,000K) – expected NDx:
PI:
Risk for Injury Activity Intolerance Risk for infection Bed rest Avoid Contact Sports Reverse Isolation Blood transfusion Bone marrow transplant
HEMOPHILIA -
inherited – bldg disorder TYPES:
a. b. c.
Hemo. A - deficiency in factor 8 Hemo. B - deficiency in Factor 9 Von Willebrand’s Dses – common in male and female
HEMPPHILIA A and B mother to male)
Autosomal Recessive Link (from
Von W Dses - Autosomal Dominant – Mother and Father IDIOPATHIC THROMBOCYTOPENIC PURPURA (ITP) or WERLHOF’S DSES -
common in BLACKS; cause: idiopathic
S/S: Hemarthrosis – bldg between joints that usually affects ankle, knee and elbow joints; Hematoma Hematuria
58 Hematemesis (above mentioned are signs of HEMORRHAGE) Lab Data : PROLONGED CLOTTING TIME Nsg Dx : Risk for Injury PI : SAFETY then RICE (REST, IMMOBILIZE, COLD COMPRESS, ELEVATE) For JEHOVAH’S (cryoprecipitate) instead
–
use
plasma
pt w/ IDA has NSG DX of ALTERED NUTRITION LESS THAN BODY REQUIREMENTS. w/c of the ff shld the nurse instruct the pt to do - INCLUDE VEGS. AND MEAT in your diet at least 1 meal a day; w/c of the ff is the priority intervention for pt w/ IDA – PROVIDE BED REST ALTERNATING w/ activities; w/c of the ff is indicative of thrombocytopenia HEMATURIA
expander
TIPS FOR BLOOD DISORDERS If all of the ff data were obtained by the nurse, w/c one is MOST SUGGESTIVE of CARDIOGENIC SHOCK - Inc. HRate from 84 to 122 bpm; The nurse admitted a 4 yo child with SICKLE CELL DSES – the priority for the patient is – HYDRATION; w/c of the ff is TYPICAL for patient w/ ANEMIA SHORTNESS OF BREATH ON EXERTION; common manifestation of LYMPHOCYTIC LEUKEMIA is – PETECHIAE; a mother of 15 mos old child with IDA makes the ff comment. w/c one is related to child condition - “MY CHILD DRINKS 2 QUARTS OF MILK/DAY”; a 7 yo boy with HEMOPHILIA was admitted. w/c of the ff is EXPECTED MANIFESTATION – HEMARTHROSIS;
CARDIOVASCULAR PEDIATRICS FETAL CIRCULATION
59 3
FETAL
STRUCTRUES PLACENTA DUCTUS VENUSUS
UMBILICAL VEIN LIVER (functionally,
closes at birth) Vena Cava UMBILICAL ARTERIES Right Atrium FORAMEN OVALE (functionally, closes at birth) AORTA R
Ventricle
LA
LV LUNGS L VENTRICLE
DUCTUS ARTERIOSUS (functionally closes by 3-4 days at birth) L ATRIUM P. ARTERY AORTA
Therefore, if these 3 fetal CONGENITAL HEART DISEASE
structures
will
not
close,
60
CONGENITAL HEART DISEASE ACYANOTIC HEART DSES CYANOTIC HEART DISEASE
Signs and Symptoms: Difficulty feeding Retarded Growth Tachypnea/Tachycardia Frequent URTI ANS – brow seating Complication: CH Failure (check for “murmur”) CVA (due to plycythemia – Inc RBC) Lab Data: 2 D Echo Nsg Dx: Altered Tissue Perfusion
Dec Pulmonary Bld flow Decrease Pulmonary
Obstructive CHD
PI : Oxygenation Surgery If < 2yrs old prepare the patient the moment the diagnosis was confirmed/ determined;
Vent. Septal Defect (most common) Pulmonary Stenosis Tetralogy of Fallot (most common) Atrial Septal Defect Aortic Stenosis Transposition of the Great Vein Patent Ductus Arteriosus Coarctation of the Aorta Truncus Arteriosus Tricuspid Atresia
Usually due to: - Maternal Infection – measles, c. pox - Age 40 and above - Medical Conditions – DM - Alcoholism
For 2-7 yrs old – surgery is equal to child age ( ex 3yo, therefore prepare the child 3 days prior to surgery) If > 7yo – parents decision
61 -
tet spell – squatting w/ cyanosis LAB DATA : 2 D-echo Complication : CVA – check for RBC Count Nsg Dx : Risk for Injury PI :
Oxygenation Position the Pt. : SQUATTING Surgery
PATENT DUCTUS ARTERIOSUS
COARCTATION OF AORTA
connection problem : P Artery and Aorta “machinery-like murmur” (+) brow seating (+) retarded growth (+) tachycardia/ tachypnea
Higher BP in the Upper Extremities and Lower BP in the Lower Ext.
LAB DATA : 2 D-Echo CVP PExam Nsg Dx : Altered Tissue Perfusion PI :
Oxygenation INDOMETHACIN
ACYANOTIC POSITION: ORTHOPNEIC (position for CHF) then SURGERY
TETRALOGY OF FALLOT pulmonary stenosis, coarctation of aorta, right vent. Hypertrophy, vent septal defect “boot-shape heart”
Lab Data : BP, 2 D-Echo PI :
Oxygenation Position the patient: Orthopneic or semi – fowler’s position
62 KAWASAKI’S DISEASE due to acute vasculitis (inflammation of bld vessels) of the heart; especially to JAPANESE children and toddler 5yo and below
w/c of the ff data in mother health history indicates a risk factor for congenital heart disease – ADVANCE AGE; when admitting a pt w/ suspected congenital heart disease, w/c intervention is priority – decreasing the metabolic demand of the heart
S/S : High Spiking Fever for 5 Days Lymphadenopathy Strawberry Tongue Palmar and Feet Desquamation Lab Data : No Specific Diagnostic test Check ECG Nsg Dx :
Altered Tissue Perfusion Altered Thermoregulation Altered Skin Integrity
Diet :
High CHON
TIPS FOR CARDIOVASCULAR – PEDIA w/ of the ff is an OUTSTANDING SYMPTOM OF CARDIOVASCULAR PROBLEM in children – difficulty in feeding; w/c of the ff is an appropriate intervention for a child who keeps on squatting because of Tetralogy of Fallot - if LESS THAN 1 yo – flex lower extremities towards the abodomen; a child who was brought in to a well baby clinic turns cyanotic while crying – REFER to the physician; the BLD VESSELS INVOLVE in PATENT DUCTUS ARTERIOSUS – pulmonary artery and aorta;
CORONARY ARTERY DISEASE (CAD) Main Problem : NARROWING and OBSTRUCTION of Coronary Arteries which could lead to HYPOXIA – reversible (which could further progress to ANGINA) and or ISCHEMIA – irreversible (that could progress also to dev’t. of SCAR FORMATION that can lead to MI). Risk Factors: Family History Atherosclerosis Smoking Elevated Cholesterol HPN
63 Obesity Physical Inactivity Stress
CAD
HYPOXIA
ISCHEMIA NECROSIS
ANGINA
PAIN Myocardial Infarction – “ jaw
pain”
MTOCARDIAL INFACRTION
ANGINA
this leads to decrease O2 – and will result to the conversion of aerobic metabolism to anerobic thereby resulting to the production of LACTIC ACID – that will stimulate the nerve ending of the heart w/ will produce/ result to PAIN that is precipitated by: EATING Elimination – due to valsalva manuever Exercise/effort/ exertion Emotion Extreme Temperature – “cool temp” – vasoconstriction sEx
Precipitated by 6E’s Pain confined at sternal area Pain that resembles “indigestion”, crushing, excruxiating Pain that resembles “pressure” Pain radiates to the L Jaw, L arm, L shoulder Relieved by SO4 Opiods (MORPHINE) Relieved by rest & NITROGLYCERIN Pain occurs AFTER MEAL (post cebum) or AFTER ACTIVITY SAME S/S of above mentioned + SHOCK s/s – esp to CARDIOGENIC SHOCK w/c is due to PUMP Failure – that leads to dec cardiac Output that leads further to CHF.
64 ECG – initial change is ST SEGMENT DEPRESSION w/ SAME T WAVE INVERSION
b.
Diet : Low Na and Low Cholesterol
Increase CHOLESTEROL SAME HDL – “good” or Healthy – liver for metabolism – 30-80 LDL - “bad” – peripheral vascular system – bld vessels60-80 CARDIAC ENZYMES #1 Myoglobin SAME Troponin CK – within 2-3 days LDH 1&2 – within 10-14 days
HEALTH TEACHINGS:
Nsg Dx : PAIN Altered Tissue Perfusion Impaired Gas Exchange
Identify types of Angina: Stable Angina – predictable – angina that occurs
w/ activity;
Priority : Airway (Oxygenation)
Unpredictable – relieved by Nitroglycerin;
Goal of CARE
Variant/ Prinzmetal – severe form of Angina;
a. To decrease oxygen metabolic demand - position : SEMI-FOWLER’S - administer O2 as ordered - administer meds:
Nocturnal Angina – occurs at night;
MI : Morphine SO4 – monitor RR, effective : (-) pain, ANTIDOTE : Naloxone HCL – Narcan ANGINA : Nitroglycerine –
dark container give b4 activity maximum of 3 doses, 5
mins interval
Decubitus Angina – when pt is lying down Intractable Angina – unresponsive to tx Post MI Angina For patient with MI – focus on complications : a. PVC or PVBeats – defibrillation/ cardioversion b. Ventricullar Fibrillation – Lidocaine – s/e “rashes”
effective: tingling sensation, sublingual provide rest – due to pain
CARDIOVERSION DEFIBRILLATION
65 - synchronize unsynchronized - esp. for VTACH w/ PULSE PULSE
- for VTACH w/o
SEX – for pt w/ MI – resume if pt tolerate 2-3 plights of stair w/o pain; - take meds b4 sex; - position during sex : passive – let the girl do her share
ACTIVITY – advised pt to have frequent rest period; DIET : avoid PROCESSED FOODS; MILK Salty Sea Foods Pastries – esp. yellow cake
FOR ANGINA APIN – instruct patient to report pain that last more than 2o minutes (indicative of MI); Weak or absent PULSE – indicative of VENTRICULLAR FIBRILLATION Report NECK VEIN DISTENTION – indicative of CHF complication Report BLEEDINGs – especially to pt on THROMBOLYTICS – t-PA and Streptokinase
CONGESTIVE HEART FAILURE main problem : PUMP FAILURE – inability of the heart to pump an adequate amount of blood to meet the metabolic demands of the body
how will the heart compensate? The HEART will pump harder- Inc HR (tachycardia) – that will result to enlargement of the heart muscle (hypertrophy) – w/c can lead to dilatation and congestion of the cardiac muscles - thereby resulting to decrease in the cardiac output.
PUMP FAILURE EFFECTS: Backward Effects : backflow of blood – systemic congestion; Forward Effects : decrease cardiac output – dec in tissue O2 perfusion – that leads to overwork respiratory system LEFT HEART FAILURE – early signs of CHF Therefore, Right Heart Failure – will be the late signs of CHF as complication of LHF Risk Factors to Heart Failure: - Arrythmias - Coronary Dses & HPN - Renal Failure LEFT SIDED HF – dyspnea and other “pulmonary s/s” – “crackles” RIGHT SIDED HF – systemic effect –
distended jugular vein Ankle edema Ascites Hepatomegally
66 LEFTS SIDED HF HF
RIGHT SIDED
Lab Data : Swan Ganz 12, V Cava – 5-12) PAP (N 20-30) PCWP (N 8-13)
CVP (N R – 0-
X-ray Nsg Dx :
HYPERTENSION INDUCED HPN X-ray
MP : blood pressure higher than Elevation of BP that occurs after 20-24 140/90 (hypertensive state) (5 mos- age of viability) wks of gestation
Altered Tissue Perfusion Ineffective Breathing Pattern – for LHF Fld Volume Excess – for RHF
PRIORITY : Oxygenation Position: Semi-Fowler’s Administer: Digoxin – absorb in GI Vasodilators Diuretics Morphine – for CHF – it causes pheriperal vasodilation by Decreasing the amount blood going back to the heart. DIET : LOW Na – NO PMS HEALTH TEACHINGS : a. Activity – rest b. dietary counseling – NO PMS c. report s/s of complications DIGITALIS – D. Toxicity: yellow vision; Muscle weakness (hypokalemia) – that can lead to arrythmia Dyspnea – s/s of pulmonary edema;
PREGNANCY
pre hypertensive phase 120/80, therefore N BP : 110/70 if BP elevated B4 20-24 wks & cont after delivery – CHRONIC HPN Risk Factors:
Levels of PIH
Common in BLACKS; a. HYPERTENSIVE DISORDER OF PREGNANCY Obesity - INC. BP + EDEMA & Proteinuria (s/s of PRE-ECLAMPSIA) Stress Smoking b. PRE-ECLAMPSIA S/S + convulsion, Abdl pain & Headache - ECLAMPSIA PHASE c. ECLAMPSIA + Bleeding = HELP SYNDROME TYPES: a. b. c. d.
ESSENTIAL HPN – cause – unknown BENIGN – usually of long duration, onset is CHRONIC MALIGNANT – acute or abrupt onset, short in duration SECONDARY – related to existing medical condition
67 HPN IN PREGNANCY – usually related to generalized spasm of the arteries PRE-ECLAMPSIA TYPES: a. MILD - .5-1GM) b. SEVERE
BP 140/90, PROTENURIA is <5mg/hr (N BP 160/90, PROTENURIA is >5mg/hr
PIORITY:
HEADACHE and ABDOMINAL PAIN – s/s of ECLAMPSIA, indicative of impending convulsion.
Stabilize BP
How? I. Non-Pharmacologic Features
ECLAMPSIA + BLEEDING = HELP SYNDROME H – emolysis E – levated Liver Enzyme L – ow P- latelet (All are signs of bleeding) S/S of HPN: Headache Retinal Hemorrhage Edema above s/s can further lead to complications: Coronary artery dses CHF Chronic Renal Failure CVA LAB DATA: Blood Pressure Elevated Cholesterol For PIH : (+) Proteinuria, Inc BP and Inc Cholesterol Nsg Dx: Altered Health Maintenance Risk for Injury
Stress Management Deep breathing Diet : Low Na/ Cholesterol Position : if inc BP – supine position
II. PHARMACOLOGIC MEASURES Antihypertensive Diuretics Aspirin Antilipimic - simvastatin & lovastatin – give after meal nighttime Monitor liver Funx test – meds above are hepatotoxic Pts w/ PIH meds: a. MgSo4 – antidote is CAgluconate b. Darkened room – to dec stimulus thereby preventing convulsion
68
PERIPHERAL VASCULAR DISEASE Arterial Obstruction
Venous
Obstruction Color pallor Edema (-) or mild Nails brittle nails Pain intermittent claudication (pain @ gastrocnemeus area) Pulse (-) Temperature cold Ulcer dry & necrotic
ruddy (+) & severe N homan’s sign (+) warm wet
TYPES: BURGER’S DSES RAYNAUDS ARTERIOSCLEROSIS OBLITERANS (THROMBO ANGITIS OBLITERANS) common : MALE
MALE
AREA Lower Ext. Lower Ext AFFECTED :
FEMALE Upper Ext – 97% 3% - lower ext
Affects arteries Arteries ONLY and veins MP :
Upper &
Arteries ONLY
“Angitis” – inflam. of Spasm of Arteries Hardening of arteries due to fatty deposits Arteries & veins of lower ext of Upper & lower ACUTE CHRONIC
INTERMITTENT - (+) pain usually related to
69 - (+) pain that narrowing of blood vessels. accompanied by color changes: PALLOR that progresses to CYANOSIS then REDNESS & aggravated by exposure to cold – NO SHOVELING OF SNOW & COLD BATH & exposure to cold – wear gloves S/S:
Outstanding s/s is INTERMITTENT CLAUDICATION – pain that worsens w/ activity or pain that is relieved by rest. - aggravated by smoking – causes further narrowing of bld vessels LAB DATA : Inc WBC & ESR Inc Cholesterol and Ca
DOPPLER USG
Nsg Dx: Altered Tissue Perfusion same Pain -doPI :
Relief of Pain
-do-
same -do-do-
MEDS : (for all types)
Anticoagulants Vasodilators (papaverin – pavabid) Antihypertensive
DIET : Low Cholesterol
VARICOSE VEIN PHLEBOTHROMBOSIS
THROBOPHLEBITIS
weakening of venous valves; CLOT + Inflammation Clot job related (prolong sitting/standing) pregnancy hereditary secondary to existing medical condition s/s : dilated tortous vein dragging sensation “heaviness” edema (unilateral/ bilateral) – tape measure to monitor leg circumference Pain Lab data: 1. conservative test – TRENDELENBURG TEST – pt lie down, elevate/ raise the legs then stand up and observe for bulging of vein; 2. Nsg Dx :
DOPPLER USG PAIN Altered Tissue Perfusion
Hx Teachings :
Elevate the legs above the heart;
70
Use support stockings; Surgery – vein ligation & stripping Sclero therapy – injection of sclerosing agents to make wall stronger thereby preventing veins to bulge.
NO MASSAGE – coz it may dislodge the clots; KNEE HIGH STOCKINGS; COLD COMPRESS
ABDOMINAL AORTIC ANEURYSM (AAA) - weakening of portion of abdl aorta – leading to dilation; - could be related to aging and HPN TYPES:
Prepare pt for Surgery
CARDIO-PULMONARY RESUSCITATION (CPR) indicated for cardiac arrest when pt is BREATHLESS and PULSELESS; shake the pt – are you ok? If breathless & pulseless then; ACTIVATE the EMS – Help! CPR (1 or 2 rescuer : 15 : 2) In 1 minute, there will be 80 compression and 15 – 20 rescue breaths Depth of Compression : 11/2” – 2”
Fusiform - entire wall is affected Dissecting - part of inner intima and media was dissected w/c lead to the pushing of tunica adventitia to bulge Saccular
If too deep - it may fx the liver Effect of CPR : #1 (+) Pulse; #2 skin color
S/S: Pulsating Abdl Mass Low Back Pain Higher BP in Upper Extremities If RUPTURE occurs – could lead to SHOCK LAB DATA : PRIORITY :
Altered Tissue Perfusion Risk for Injury
NO ABDOMINAL PALPATION bec it may lead to rupture – PLACE WARNING AT THE DOOR OF THE PT.
TIPS FOR CARDIOVASCULAR – ADULT A nurse is assigned to a pt with arterial dses of lower extremities, w/c of the ff is expected – calf pain after short walking (intermittent claudication); A pt was diagnosed w/ MI develop atrial fibrillation – this may possibly lead to – CEREBRAL EMBOLISM; A pt w/ CHF was admitted exhibiting confusion, disorientation, visual disorders & hallucination – the nurse best action is to – CALL THE PHYSICIAN;
71 A nurse is assessing a pt w/ MI – w/c of the ff is the characteristic of PAIN – pain radiates to the jaw; In utilizing mind over body principle for pt w/ HPN – w/c intervention is appropriate - relaxation and stress mgt; Pt exhibits intermittent claudication – another sign of peripheral dses is w/c of the ff – tropic skin changes; Ff MI, when shall I resume sexual activity? – when you can climb 2 plights of stairs w/o shortness of breath then sexual activity is safe; A pt has R sided CHF, w/c of the ff is expected – hepatomegally; Apt w/ CHF who is taking diuretics exhibits the ff, w/c requires further investigation (not expected to pt) – wt gain of 3 lbs in 2 days; In addition to assessing a pt w/ Burger’s Dses, w/c of the ff data supports the Dx. – smoking; A pt with R sided HF will manifest – distended jugular vein
use steth directly on pt. skin – because clothing my interfere w/ auscultation; when the pt chest is hairy, wet the hair w/ dump cloth – because dry hair interfere w/ auscultation Consideration w/ Pediatric Patient: when assessing pediatric pt, RR is affected when – therefore check RR FIRST; Note for chest indrawing (if +, may indicate Pneumonia) and rapid breathing Reportable Signs and Symptoms : common TO ALL RESPIRATORY DISORDERS “RE TACHY TACHY D C” RETRACTIONS - #1 or Early sign for respiratory distress; Tachycardia Tachypnea Dyspnea Cyanosis – late sign of respiratory Distress Key Points for Assessment - note for abnormalities in RATE, RHYTHM & DEPTH Common CHARACTERISTIC in Breathing
RESPIRATORY General Consideration: use the DIAPHRAGM of the steth when assessing breath sounds;
BIOTS – increase in depth followed by apnea; - pt w/ neuro impairement Cheyne-Stroke – increase in rate and depth of breathing followed by apnea; - nero case Kussmauls – deep rapid breathing; Apneustic – forceful inspiration followed by slow expiration – dying patient
72 At birth, the child can maintain temperature by burning brown fat – and increase burning – bi products is Increase fatty acids that will cause acidosis – that can worsen the Resp. Distress Syndrome – a group of symptoms (mgt: maintain temperature). HYPOVENTILATION
Cause: Lack of O2
a. b. of Apparent Life Threatening Events c. who died w/ SIDS (usually 2-3 sis/ bro – died) d. Dx Procedures:
Pre-Term; Those w/ episodes Siblings of those Hypoventilation
Cardioneumogram – measures O2 Polysonography ABG Analysis
Effect:
ACIDOSIS Tx :
Administer Theophylline (N 10-20 mg/ml) S/Effects: NAV and Insomia Caffeine Assist mother threu grieving process
HYPERVENTILATION ALKALOSIS Cause : lack of CO2 – the pt will decrease rate of breathing to save CO2. co2 then combine with H2O to form carbonic acid – if inc, can lead to acidosis – and the brain will compensate by hyperventilating – and increase elimination of CO2 will cause ALKALOSIS.
Hx Teaching : Teach parents CPR (esp to Apnea of Infancy)
ASTHMA MP : Inflammation of bronchioles that leads to excessive mucus production that resulted to narrowing and obstruction. Risk Factors : Environmental factors Emotion Effort/ Exercise
APNEA OF INFANCY
SIDS/ CRIB DEATH
Occurs in Full Term Baby (37wks onwards) occurs in Pre-term
Usually
s/s : episodes of APNEA, TACHYCARDIA Factors: and Cyanosis
Risk
S/S :
WHEEZING sound – due to obstruction Orthopnea Whitish Sputum
Lab Data : Pulmonary Funx test Incentive Spirometer
73 Nsg Dx :
Ineffective airway Clearance
PI :
AIRWAY
Intervention : Bronchodilators – theophylline Rest Oxygen – low flow (1-2 l/min) – higher than this will result to decrease in the stimulus for breathing – w/c is CO2 Nebulization Chest Physiotherapy – b4 meals or at bed time High Fowlers Intermittent Positive Pressure Breathing Aerosol Liberal Fluid Intake Meds :
Aminophylline Steroids Theophylline Histamine Antagonist Mucolytic Antibiotics
multi system dses (GI and Respiratory System) characterized by excessive mucus production by exocrine glands. Respiratory
GI
Hereditary
Autosomal Recessive
For each pregnancy -
TRAIT TRANSMISSION – 50% Chance for DISEASE TRANSMISSION –
25% S/S : MECONIUM ILEUS – within the 1st 24-36 hrs – if baby fail to defecate – suspect for CF; ABDL DISTENTION Malabsorption Syndrome – STEATORRHEA – foulsmelling stool w/ Inc Fats & Bulky Salty to Kiss – bec skin becomes impermeable to Na Common Complications: because of thick mucus plug MALE – Aspermia – low sperm count Sterility FEMALE – Difficulty in conceiving Nsg Dx :
Hx Teachings : Appropriate rest; Activity – avoid those that will expose pt to allergens; AVOID PROPANOLOL and ASPIRIN – causes BRONCHOSPASM; Exercise – “blowing exercises” – bubbles, trumpet
CYSTIC FIBROSIS
Knowledge Deficit Altered Elimination Altered Sexual Functioning
Lab Data : Sweat Chloride Test – N (if sweat) 10 – 35 mg/dl – INCREASE IF (+) CF (if serum) 90 – 110 mg/dl -doPI : since two system are affected: Respiratory Therapy – blowing of trumpet, Increase Fluid Intake; GI Therapy – Administer Pancreatic Enzyme (pancreatin, pancrease, viocase)
74 GIVEN WITH EACH MEALS Effective : if (-) fat at stool
(-) FEVER (+) FEVER-low grade (+) FEVER-moderate (+) STRIDOR WHEEZING
(+) STRIDOR
(+)
Hx Teaching : Refer parents to GENETICIST STRIDOR – is present when the affected part is LARYNX. Lab data:
P Exam ABG’s
Nsg Dx :
-do-
ELIZA -do-
INEFFECTIVE AIRWAY CLEARANCE
PI : Airway – Endotracheal Tube (Tracheostomy Set - #1) – to facilitate airway; Humidity – place infant in MIST TENT or CROUPETTE Nsg care: CROUP DISORDER ACUTE LARYNGITIS LTB RSV/ BRONCHIOLITIS (Laryngotracheal Bronchitis) (Respiratory Synctial Virus) common in TODDLER INFANTS & TODDLER INFANTS usually (less than 6 mos) VIRAL
VIRAL or BACTERIAL VIRAL
Inflammation of LARYNX Inflam. of LARYNX & TRACHEA Inflam. Of BRONCHIOLES “barking-metallic cough” “harsh-brassy cough” “paroxysmal-hacking cough”
change clothing frequently coz mist will dampen child clothings; TOYS while inside the tent: PLASTIC TOYS “no battery operated & no friction wheel toys” at HOME: we can use NIGHT or MOIST air outside and hot shower mist at the comfort room – for child to inhale Antibiotics – Antiviral – Ribavirin Hx Teachings : SYRUP OF IPECAC – for Croup – it induces vomitingbec it will stop the spam thereby preventing further coughing.
75 Over distention of Alveoli Bronchus
Inflammation of Gelatinous sputum + “RE
TACHY TACHY D C” Risk Factors: (+) (+) (+) (+) (+)
Allergy Environmental factors Pollen Elevated Immunoglobulin E (IgE) Smoking (esp to passive smokers)
S/S: RE TACHY TACHY D C + “barrel-shape test” – there is an INCREASE in ANTERIOR and POSTERIOR DIAMETER of the chest Lab Data : ABG’s – to check for respiratory acidosis CXrays Nsg Dx : #1 Ineffective Airway Clearance – due to narrowing & obstruction #2 Ineffective Breathing Pattern PI : Chronic Obstructive Pulmonary Disease (COPD) MP : group of disorders of respiratory system that lead to obstruction or narrowing of airways.
AIRWAY 1-2 L/min; Meds: Bronchodilator – Atrovent Exercise: Blowing; Rest periods in between activities
During ACUTE attack, the POSITION OF CHOICE : ORTHOPNEIC
PNEUMOTHORAX EMPHYSEMA
BRONCHITIS ASTHMA
MP : partial or total collapse of lungs due to:
76 Types : BLEB – over TENSION
Open Pneumothorax – TRAUMA Spontaneous Pneumothorax - due to rupture of distention of alveoli Tension Pneumothorax – due to INCREASE IN
S/S : Diminished Breath Sounds – (-) b. sounds to area auscultated; (+) Dyspnea; (+) Restlessness Nsg Dx :
Impaired Gas Exchange Ineffective Breathing Pattern
PI : Chest Tube Drainage System – restores the (-) pressure within the thoracic cavity Anterior chest tube – drains the AIR Posterior chest tube – drains FLUIDS
PNEUMONIA (PNA) MP : there is INFLAMMATION of ALVEOLAR SPACES that leads to exudation and consolidation of the lungs. LEGIONARES DSES – acute bronchopneumonia in elderly, alcoholic & Immunosuppressed pt - management same w/ pna
VIRAL PNA
BACTERIAL
PNA Fever : moderate-high
(+) low-moderate
(+) fever
Cough : (+) Non productive – “thin-watery” Productive – “rusty”
(+)
WBC :
Elevated
No change or slight
Lab Data :
Xray and ABG’s
Nsg Dx : Impaired Gas Exchange – due to exudation and consolidation of Alveoli PI :
TB
Airway – O2 Position : Semi-fowler’s or Orthopneic Bed Rest Inc Oral fluid intake Antibiotics TCDB (turning, coughing, & deep breathing)
HISTOPLASMOSIS MYCOBACTERIUM AVIUM
COMPLEX Bacterial CAPSULATUM) thru
Fungal (from HISTOPLASMA Bacterial from BIRD MANURE – soil & transmitted
77 inhalation Droplets & Airborne Droplets & Airborne Droplets & Airborne Risk Factors:
Rifampicin INH Streptomycin Ethambutol take above meds for 6-12 moths to avoid resistance
ASIAN IMMIGRANT IMMUNOSUPPRESSION MALNUTRITION S/S : ACTIVITY
same: a to e + FOREST RELATED same with TB Ask client if came from AVIARY
a. initially asymptomatic; b. low grade fever that occurs in the afternoon; c. body malaise or weakness; d. coughing w/ bld streaked sputum; e. weight loss Lab Data : Histoplasmosis
Histoplasmine Skin Test – for
Mantoux Test Xray – confirmatory test Sputum - @ least 2 (-) to be effective
TIPS FOR RESPIRATORY you observed a nurse caring for a child in a CROUPETTE, if you are the nurse in-charge, what would be your #1 PRIORITY? – changing the linens & clothings to keep child always dry; which data in the past medical history of the pt. supports a dx of cystic fibrosis – MECOMIUM ILEUS in the neonate; the primary goal of care for pt w/ bronchiolitis is to – minimize oxygen expenditure; w/c of the ff intervention being carried out by LPN would require immediate intervention – suctioning the pt for 20 seconds;
Nsg Dx : Infection; Ineffective Breathing Pattern PROPHYLACTIVE TREATMENT OF TB – INH for TWO WKS (take Vit B6 to avoid NEUROPATHY) MEDS : Antibiotics
Antiviral Meds
a client w/ TB will experience - low grade fever;
a pt is diagnosed w/ emphysema – w/ of the ff s/s would the nurse expect to have – barrel shape chest; a nurse caring for a pt w R Lower Lobe PNA shld put the pt in w/c of the ff position to enhance postural drainage – L Lateral w/ the Head Lower than the Trunk
78 c. self insulin administration – allowed to child 9 yo and above Reportable S/S : skin changes – “have you noticed any change in your skin color” (“bronze skin pigmentation – addison’s dses) Inc. temperature S/S of Shock Keypoints : Specimen characteristic is usually affected by STREE, DIET and Normal Body Rhythm
DAY
7
(Feb
10, 2005)
PKU AUTOSOMAL transmission (inherited)
RECESSIVE
PATTERN
of
MP : ENDOCRINE General Consideration Explain to the pt the MOST COMMON METHOD of assessment: a. b.
Direct methods – specimen : blood and urine Explain the methods of gathering the specimen
There is Absence of Phenylalamine Hydroxylase (the one that converts Phenylalamine to Thyroxine ( a precursor to Melanin). Therefore (-) PH leads to accumulation of phenylalanine at the brain that leads to Mental Retardation. S/S : Initially – asymptomatic For OLDER CHILDREN :
Consideration for PEDIATRIC PATIENT a. b.
Involve the parents of the child; Incorporate food preferences 2 servings of popcorn – HOW MANY RICE TO GIVE UP
=1 if sandwich = 1 rice
Diarrhea Anorexis Lethargy Anemia Skin Rashes
and
seizure Musty odor of urine (due to phenyl pyruvic acid) Since (-) melanine: hair : blonde
79 Eyes: blue Fair Skin
LYMPHOCYTIC THYROIDITIS or JUVENILE HYPOTHYROIDISM
Lab Data : GUTHRIE CAPILLARY BLD TEST – initial screening – done after the infant has ingested CHON for a minimum of of 24 hrs.
Cause :
Autoimmune or genetics
MP :
Decrease in T3 and T4
Secondary screening : done when the infant is about 6wks old – test fresh urine w/ PHENISTIX – WHICH CHANGE COLOR
S/S :
Dysphagia Enlarge thyroid All s/s of hypothyroidism (decrease metabolism)
Phenylalanine level greater diagnostic of PKU (4mg/dl – indicative)
Nsg Dx :
Knowledge Deficit Activity Intolerance
than
8mg/dl –
PI : no tx because it regresses (only temporary) spontaneously
Nsg Dx : Knowledge Deficit Altered Thought Process Risk For Injury PI : Dietary Modification : LOW CHON and Low Phenylalanine Diet until adolescent or til 10 yo – bec b4 this time the brain mature MEDS :
Lofenalac – 20-30mg/kg/day
Hx Teachings : Inform parents of the foods to be avoided; - prepare special education to parents Provide list of foods allowed;- prepare special education to parents Refer to geneticist Untreated PKU can result in failure to thrive, vomiting and eczema – and by about 6 mos, signs of brain involvement appear.
CRETENISM or CONGENITAL HYPOTHYROIDISM disorders related to absent or non-functioning thyroid; newborns are supplied with maternal thyroid hormones that last up to 3 mos; initially asymptomatic s/s begins 2 – 3 months
behavioral s/s physical s/s – large tongue & protrudes - apathy – “well behave” from mouth retarded growth - intolerance to cold mental retardation
80 Prevention: neonatal screening blood test; Without treatment, mental retardation and developmental delay will occur after age 3 mos; Lab Data : Decrease T3 and T4 Nsg Dx :
Knowledge Deficit Risk for Injury
Meds : Single morning dose of Synthroid for “LIFE” – oral thyroxine and Vit D as ordered to prevent M. retardation (adverse effect of meds : insomnia, tachycardia, and nervousness – REPORT ASAP) PI :
correct the deficiency
Hx Teachings : Warm environment (bec there is Hypothermia w/ cool extremities); Low calorie diet : since there is decrease metabolism; Special education ENDOCRINE GLANDS 8 glands (ductless)- they secrete the hormone directly to bld stream 1. 2. 3. 4. 5. 6.
Pineal Gland Pituitary Gland Thyroid Gland Parathyroid Gland Thymus Gland Pancreas
7. 8.
Adrenals Gonads (testes & ovaries)
Glands
UNDER
OVER
PITUITARY
Diabetes Insipidus
SIADH
THYROID Hypothroidism Hyperthyroidism (Myxedema) Basedows, Parrys) PARATHYROID Pancreas ADRENALS Cushings
Hypo
(Graves, Hyper
DM Addison’s Dses Conns
81 - Non-Ketosis Prone GESTATIONAL DIABETES - occurs during pregnancy Types According to WHITE’S Classification PANCREAS TYPE Alpha Cells
BETA CELLS
ONSET DURATION A CHEMICAL DIABETES
(+) Increase Bld Sugar
Islets of Langerhans B
After the age of 20
C 10-19 years
Bet 10 – 19 yrs old
D More than 20 yrs
Before 10 yrs old
D1
Before 10 yrs old
10
years Glucagon Insulin (responsible for Decrease in blood sugar) Responsible in the increase Blood Sugar Absence Deficiency (DM Type I) IDDM
(DM Type II) NIDDM
Juvenile Onset – B4 age of 30 Maturity Onset – After age of 30; Adolescence to Early Adult Stage Pt is Obese Pt is THIN Pt is KETOSIS PRONE NONKETOSIS PRONE MODY – DM III - combines features of DM Type I & 2; - Maturity Onset that occurs in young adult; - OBESE, b4 age of 30
D2
>20 yrs
D3 Beginning Retinopathy D4
w/ calcification of arteries
D5
DM w/ HPN
E F Nephropathy)
w/ calcification of Pelvic Arteries w/ nephropathy (Diabetes
H
Diabetes Cardiopathy
R
Diabetes Retinopathy
82 T
w/ Transplant of the Kidney INTERMEDIATE NPH AFTERNOON/ AFTERNOON SLOW
-
LATE IN THE
Protamine Zinc - DURING NIGHT Ultralente
INSULIN: NEUTRAL AREA DIABETES MELLITUS
Best Site is ABDOMEN bec it is a SUBQ – 90 degree angle for insulin
syringe MP : Deficiency in INSULIN – either absence or deficiency of insulin that leads to alteration in the metabolism of CHO, CHON and FATS. Cause:
unknown
R. factors : Autoimmune Genetic Stress S/S :
Polydipsia Polyuria Polyphagia – the stave cells send message to the brain to eat more Wt loss Nsg Dx :
Knowledge Deficit Altered Nutrition
PI : Correct the deficiency- HOW? Diet : well balance diet – CHO – 50-70% (main source of energy and sugar for DM pt.) Insulin – for Type 1 Hypoglycemia Most Approximately to Occur RAPID
Regular Insulin - BEFORE LUNCH
40 degree angle if noninsulin syringe Complication of INSULIN ADMINISTRATION: Lipodystropy Dawn’s Phenomenon – hyperglycemia that occurs at dawn – Early AM due to over secretion growth hormone treatment: GIVE INSULIN – NPH at 10 PM to prevent hyperglycemia at early AM SOMOGYI Phenomenon – rebound hyperglycemia (tx: administer insulin)
Antidiabetic Agent;
(2x a day);
Blood Sugar Monitoring – in AM and supper time
Ensure adequate food intake;
Transplant of Pancreatic Cells;
Exercise – it will decrease insulin requirement (in pregnancy/stress – Increase insulin req) Scrupulous foot care – check up w/ podiatrist - foot powder, snugly fitting shoes, cut toe nail straight across
83 - cut toe nail across - avoid going barefoot - always dry in between toes
(Insulin Reaction) Coma) - BLD SUGAR BELOW 50
(Diabetic
DKA
HHNK
Risk Factors : Modification for Pregnant Pt with DM +300Kcal; Insulin Requirement (dose will be adjusted on 2 nd & 3rd Trimester); AM Dose: PM Dose:
2:1 for Regular to NPH 1:1 for R:NPH
Missed meals; Increase or Overdose of Insulin; Insulin Too much Activity Stress Infection S/S :
BABY
Lab Data : Below 50 Blood Sugar Level
Macrosomia Hyperglycemia Hypoglycemia Therefore pre-term birth RDS Complication: Uterine Atony Congenital Defects
COMPLICATION
1. Hypoglycemia sugar level above 120)
Inactivity
Dizziness Drowsiness Difficulty Problem Solving Decrease Level of Consciousness + Cold Clammy Skin, Diaphoresis
EFFECTS
MOTHER
Overeating Decrease
Hyperglycemia (bld
PI :
Administer Simple Sugar (fructose-fruit juice) Hard Candy (not chocolate – it is complex sugar) If unconscious – D50
84 DKA (Type 1) HHNK (Type 2) (Hyperglycemic Hyperosmolar Nonketotic Coma) S/S : 3 P’s + Signs of Dehydration – thirst & warm
DIABETES INSIPIDUS (Pituitary Glands – 3 lobes)
skin
Hyperglycemia pronounced GI Disturbances “Kussmaul Breathing + 3P’s Thirst and warm skin
More
ANTERIOR MIDDLE
POSTERIOR
Secrete Tropic Hormones excrete) MSH (skin color)
Store Only (does not
Lab Data : Increase Bld Sugar PI :
#1 AIRWAY #2 Fluid Regular Insulin
Nsg Dx :
Risk for Injury
2. 3.
ATHEROSCLEROSIS – hardening of
arteries; NEPHROPATHY – kidney damage;
5. OPTHALMOPATHY - w/c leads to cataract (eye exam annually); 6. -
ACTH (adrenocorticotropic hormone)
LH (luteinizing hormone);
GH (growth hormone);
Prolactin
MICROANGIOPATHY - destruction of small
blood vessels;
4.
FSH OXYTOCIN (follicle stimulating Hormone) ADH
Peripheral Neuropathy or Autonomic Neuropathy there is poor nerve impulse transmission common manifestation : impotence
85 PITUITARY GLAND
Lypressin -
-doHow : Given
ADH (anti Diuretic Hormone) – retain h20 or flds
as pt exhale to the mouth then inhale thru the nose then EXHALE to the mouth then give meds. Evaluate the effect of meds :
Deficiency: lead to D. INSIPIDUS
Excess : SIADH
(Syndrome of Inappropriate Anti Diuretic Hormone Secretion)
Due to or related to: Pituitary Tumor Head Trauma Injuries MP : Deficiency in ADH leads to fld excretion, therefore s/s same with DM EXCEPT : POLYPHAGIA
Polyuria – 21 L/day Polydypsia
LAB DATA : a. urine - decrease in specific gravity (N 1.010 – 1.025) – in DI its <1.005; b. FLUID DEPRIVATION Test - pt on NPO 24hrs B4; Nsg Dx : PI :
FLUID VOLUME DEFICIT
Administer IV Fluids Meds Synthetic ADH - Vasopressin – IM Desmopressin – INTRANASALLY- one hole of nose only
Check Specific Gravity of Urine; Monitor I & O; Monitor V/S : assess for hypovolemic shock
86
-
DWARFISM of Growth Plate - “congenital” “gigantism” ex. MAHAL slender extremities and Inc. in Height
SIADH excess ADH;
MP : Fluid Retention – result to DILUTIONAL HYPONATREMIA or H2O INTOXICATION S/S :
B4 Closure - long, ex. Marlo
Aquino
due to DECREASE NA – this could lead to the ff: NANU’S SYNDROME (hereditary) convulsion; seizure; HPN
After the Closer of Growth Plate “acromegally” - there is
Above s/s could lead to decrease LOC
coarsening of facial features +
LAB DATA : Decrease Na Level (<120 mEq/L) – hyponatremia
enlargement of the digits (inc. shoe size)
Nsg Dx :
ex. Balingit
FLUID VOLUME EXCESS
PI :
FLUID RESTRICTION Drugs – DIURETICS + ANTIHPN – if cause by TUMOR – PREPARE PT FOR SURGERY IF after surgery – POLYURIA – report ASAP – sign of DI
Lab Data : INCREASE HUMAN GROWTH HORMONE Increase Blood Sugar Nsg Dx :
Risk for Injury
PI :
Safety Meds - Parlodel – decrease secretion of growth
hormone If related to tumor : surgery PITUITARY GROWTH HORMONE DEFICIENCY
EXCESS
87 GLUCOCORTICOIDS MINERALOCORTICOIDS EPINEPHRINE NOREPINEPHRINE (ALDOSTERONE) GLUCONEOGENESIS STRESS RESPONSE – “fight or flight” - formation of sugar from Responsible for Na Retention new sources and K Excretion
GIGANTISM (long slender extremity)
DEFICIENCY IN GLUCO & MINERALO : ADDISON’S Dses EXCESS of GLUCO & MINERALO : CUSHING’S Dses/ syndrome EXCESS of MINERALOCORTICOIDS ONLY : CONN’S SYNDROME
MARFAN SYNDROME KLINEFELTERS (hereditary) (chromosomal aberrations) MP : Cardio & Eye disorder (complication) XXY Pattern (an extra X chromosome) Scoliosis chromosome – FEMALE COMPONENT
MP : X of
HUMAN BODY Problem is NON-DEVELOPMENT of SEX ORGAN
ADDISON’S
the CORTEX (OUTER)
MEDULLA
RESPONSIBLE FOR SECRETION OF: SECRETES THE FF:
CONN’S
MP : Underactivity of the Adrenal Glands Overactivity of A. Glands INC. MINERALOCORTICOIDS (there is DEC G, M & SEX HORMONES) (there is INCREASE G & M) - w/c cause K EXCRETION & ADRENOCORTICAL INSUFFICIENCY Na RETENTION
ADRENAL/SUPRARENAL
(INNER)
CUSHING
Excessive SECRETION of Excessive ALDOSTERONE - coticosteriods especially Secretion from A. Cortex GLUCOCORTICOID CORTISOL
Common: Male and Female Age 30-60) Female (30-50)
Female (bet.
RF : Could be related to Surgery – removal Tumors Related to Tumor
Related to
88 Of Adrenal Gland and or Auto Immune Reaction S/S: Dec Bld Sugar (hypoglycemia) INC BP, NA ALL S/S OF CUSHINGS Dec Na (hyponatremia) DEC K + EXCEPT HYPERGLYCEMIA Dec BP Moonface, Hirsutism, INC K (hyperkalemia) Buffalo Hump, Pendulous Abdomen Hypertension Lability of Mood (mood swings) Polyuria, Polydipsia Depression Cardiac Arrythmias – due COMPENSATORY of MSH – Inc w/cTrunkal Obesity / thin Extremities to dec K Leads to “Bronze-Like Skin Pigmentation” Hypertension Decrease Resistance to Infxn Hypotension, Weak Pulse Weight loss, Fatigue, Muscle weakness Nausea, Anorexia, Vomiting Hx of frequent Hypoglycemic Rxn Lab Data : Decrease Cortisol Level Increase Cortisol Level Hypokalemia – due Hyponatremia Hypernatremia metabolic Alkalosis Hypoglycemia Hyperglycemia Inc Urinary Aldosterone Level Hyperkalemia Hypokalemia Decrease K Nsg Dx : Fluid Vol. Deficit Risk for Injury Fld & E imbalance Fld & E Imbalance
Fld Vol. Excess Fld & E imbalance
ADDISON’S
CUSHINGS CONN’S
PI : Correct the imbalance – IV Correct the imbalance Check BP – give antiHPN Diet: Inc Na Dec K - limit fld intake Administer Steroids (Fludocortisone) DIET : Low in Calories & Na Limit the flds Admin. Hormone Replacement Therapy High in CHON, K, Ca Cortisone – give 2/3 of dose in AM & Vit D 1/3 in afternoon Meds are FOR LIFE Prevent accident & Falls Diet : Low Na, Inc K Prevent exposure to Infxn Protect client exposure to Infxn Provide rest periods – prevent fatigue Minimize stress in environment Administer SPIRONOLACTONE Monitor I & O, weigh Daily MIO & weigh Daily (aldactone) & K supplements As Rx Provide small, frequent feeding high in observe for HPN & CHO, Na and CHON to prevent Hypoglycemia & Hyponatremia
Monitor V/S, edema
Use of Table salt tablets (if Rx) or ingestion Surgery – prepare pt if cause
89 Of salty foods (potato chips) or hyperplasia if experiencing Inc. sweating
by pituitary tumor Post Surgery: poor wound
healing; report s/s of Addisonian Crisis –
THYROID severe
HYPOTENSION Avoidance of strenuous exercise esp Meds: FOR LIFE in HOT WEATHER Glucocorticoids Synthesis Inhibitors - Lysodren and Cytodren - prevents formation of Gluco…
ADDISONIAN CRISIS severe exacerbation of Addison’s dses caused by acute adrenal insuffieciency causes: strenuous activity, infection, trauma, stress, failure to take RX Meds s/s:
PI :
severe generalized muscle weakness severe hypotension hypovolemia, shock administer flds to treat vascular collapse IV glucocorticoids - Solu-Cortef and Vasopressors
Maintain strict bed rest and eliminate all forms of stressful stimuli MIO and weigh daily Protect client from Infxn Other Hx teachings: same with Addison’s
T3 & T4 Calcitonin - responsible for maintenance of METABOLISM - deposit Ca @ bones DEFICIENCY HYPOTHYROIDISM HYPERTHYROIDISM Adult: Myxedema Grave’s Disease, Basedow’s or Parry’s Dses Children: Cretenism
EXCESS
Main Problem: Slowing of metabolic process caused by hypofunction of the Secretion of excessive amount of Thyroid Thyroid Gland with decrease thyroid hormone secretion (T3 & T4) Hormone in the blood causes in the INC Of metabolic process DEFICIENCY in T3 and T4 Excess in T3 and T4 Causes: congenital surgery autoimmune
genetic
90
autoimmune
tumor
- performed to determine thyroid function (increase uptake – indicated hyperthyroidism, minimal uptake may indicate – hypothyroidism); nsg consideration : take a thorough history – thyroid meds must be D/C 7-10 days b4 the test – meds containing iodine cough preparations, and intake of iodine rich foods and test using iodine – eg IVP can invalidate the test
S/S : FACIAL EDEMA EXOPTHALMUS INTOLERANCE to COLD (+) Goiter DECREASE v/s Hypermetabolic State DECREASE GI Motility – constipation INTOLERANCE to HEAT HYPOactivity Increase Sleep – hypersomnia INC GI Motility - DIARRHEA Wt Gain in the presence of Dec Appetite Insomnia Dry scaly skin, dry sparse hair, brittle nails HYPERactivity
NSG DX : Activity Intolerance – due to Fatigue Risk for Injury (bec of hyper) (fatigue – due to hypometabolism)
Inc V/S
PI : Promote a EUTHYROID STATE same WT LOSS
even INC Appetite Warm smooth skin, fine soft hair Pliable nails Irritability, restlessness, agitation LAB DATA : Check TSH (increase) DECREASE TSH DECREASE T3 & T4 INCREASE T3 & T4 DECREASE RAIU (131) INCREASE RAIU INCREASE Serum Cholesterol Level RADIOACTIVE IODINE UPTAKE administration of 123I or 131I orally;
(RAIU)
–
HOW : a. THYROID SUPPLEMENT Admin AntiThyroid Meds – for LIFE Synthroid, Cytomel – lifetime ex. PTU & Lugols s/e: insomnia, palpitation nervousness b. DIET: low calorie Assign to private room away from excessive activity c. Maintain vital funx: correct hypothermia – maintain Quite & relaxing Activity adequate ventilation d. Provide comfortable, warm environment Provide a COOL ENVIRONMENT e. Increase flds and high fiber foods to prevent constipation,. Admin stool softener as Rx DIET : High in CHO, CHON, CALORIES f. Meds: thyroid hormone replacement – take daily Vit & Minerals w/ supplemental dose in AM to avoid insomnia feedings bet meals & at HS Monitor THYROTOXICOSIS – tachycardia NO STIMULANTS
91 Palpitations, nausea, vomiting, diarrhea, Sweating, tremors, dyspnea Protect eyes w/ dark glasses & artificial tears Monitor for AGRANULOCYTOSIS (fever, Sore throat & skin rashes) – if taking antithyroid meds. Prepare pt for surgery – 2wks before SURGERY give LUGOL’S SOLUTION - it decrease size and vascularity of thyroid gland;
MEMORRHAGE – whether the dressing is dry or intact – its not a confirmatory that there is no bleeding. To check, slip your hands at the back of the neck (bec of principle of gravity) Damage Laryngeal Nerve – to assess, ask pt to talk past surgery and if pt has APHONIA – provide communication aids – paper and pencil LARYNGOSPASM – accidental removal of parathyroid gland – therefore will lead to dec parathormones – w/c lead to dec Calcium and laryngospasm – KEEP TRACHEO SET at bedside.
TETANY – due to decrease in CA – characterized by:
- can be diluted w/
a. tingling sensation – fingers & lips b. Chvostek’s Sign – facial muscle twitching on percussion of facial nerve c. Trousseau Sign – carpopedal spasm
- report diarrhea &
- give w/ straw to avoid staining teeth; H2O or orange/ apple juice; metallic state Meds: a. Antithyroid Drugs – Prophythiouracil and Tapazole - block synthesis of thyroid hormone; - toxic effect include AGRANULOCYTOSIS b. Radioactive Isotope of Iodine (131) – Radioactive Iodine Thrapy - given to destroy the thyroid gland thereby decreasing Thyroid hormone production COMPLICATIONS OF THYROID SURGERY:
THYROID CRISIS – due to rebound hyperthyroidism Increase thyroid hormone Increase HRate/palpitation Inc Temp - hyperthermia
92 Lab Data : Decrease Ca Inc Ca (N 4.5-5.5 mg/dl) Serum Phospate Inc Dec Serum Phospate Level Skeletal Xray – reveal Inc Bone density xray –reveal Bone Demineralization Nsg Dx :
RISK FOR INJURY same
PI :
a. Safety same
PARATHYROID Parathormone
Deficiency Inc CA in the Blood EXCESS HYPOPARATHYROIDISM withdraws Ca @ bone to the bld HYPERPARATHYROIDISM MP : Dec Ca (hypocalcemia) maybe hereditary, Increased secretion of PTH that result Or caused by accidental damage to or removal in altered state of Ca, Phospate & bone Of parathyroid glands during surgery eg thyroidectomy metabolism S/S : Initial S/S: Bone Pain (esp Back Bone) Tingling lips & Fingers Disorder – kidney stones Chvostek’s renal colic Trousseau Constipation Late S/S personality changes cardiac arrythmias muscle pains
Kidney
NAV,
b. Keep Ca supplement at Bedside Inc Oral Fld intake – due to renal c. Diet: Inc Ca – spinach, sardines, seafoods calculi of having INC Ca d. Tracheo set – deu to dec Ca – Laryngospasm Diet; Low Ca Surgery – if due to tumor
93
TIPS FOR ENDOCRINE
a child w/ PKU was admitted, w/c of the ff statements made by the mother indicates a need for further instruction – “my child loves to drink milkshakes” – chon- w/c has INCREASE Phenylalanine; w/c of the ff if manifested by a child could be indicative of diabetes – bed wetting; a common manifestation of HYPOGLYCEMIA – shaky tremors; a pt post thyroidectomy develops tetany, the nurse anticipates that the doctor will most likely order – Ca Gluconate; rapid & deep breathing that occurs in diabetic pt is indicative of – KETOACIDOSIS a pt is to receive NPH Insulin at 8AM, when shld the nurse expect to have hypoglycemia – in the late afternoon; to determine the effect of PTU, the expected outcome is – Dec HR; what would be the question to support the Dx of Hypothyroidism – do you tire easily?; w/c of the ff statements made by the diabetic pt would indicate the need for further teaching – “I will be hypoglycemic if I experience emotional stress”.
GENITO-URINARY General Consideration when performing assessment of Genito-urinary system, use open-ended question- bec some pt are not comfortable talking genitals; explain the meaning of terminologies; ask the patient what symptoms bother him/her the most; Consideration for Pediatric Patient
assess for history of sorethroat; bladder capacity increase with age
infants – about 65ml
94 toddler – 300-400 ml school age – 800 – 1000 ml infants are unable to concentrate urine until the age of 1 – therefore – adequate milk intake if baby has 6-8 diapers /day;
d. e.
Increase glucose – UTI Elevated CHON – Nephrotic Syndrome or PIH
Epispadias – opening at DORSAL portion Hypospadias – opening at VENTRAL portion
bladder sphincter control develop at around 2 yo (therefore, bladder trng comes after bowel trng – 15-18 mos of age) S/S common to all Disorders of GU: a. b. c.
frequency urgency hesitancy
Reportable s/s : peri orbital edema BP Oliguria Hematuria – Early Stream Hematuria – indicate lesion at Urethra Late Stream – indicate lesion at bladder
WILM’S TUMOR congenital tumor at the kidney common in L Kidney and children below 5 yo S/S : Unilateral Abdml Mass Hematuria HPN Lab Data : CT Scan IVP NO INAVSIVE LAB/ Procedure NO BIOPSY
Key points : a.
check for wt gain
if >1lb/day – indicative of fld retention b.
characteristic of urine: color N - amber if pinkish – bldg brownish – flagyl orange – rifampicin
c. s. gravity (N 1.010 – 1.025) - if INCREASE - D. Insipidus DECREASE – D. Mellitus
Nsg Dx : Knowledge Deficit Risk for Injury PI :
AVOID/ NO ABDOMINAL PALPATION Prepare pt for Surgery and Chemotherapy
NEPHROTIC SYNDROME
AGN
95 MP : Altered Kidney Funx related to inability to retain CHON Destruction of Kidney Tissues related (therefore there is PROTEINURAI) to Group A Beta Hemolytic Streptococus
DIET :
causes: Autoimmune sorethroat congenital
POSITIONING :
INCREASE CHON, Low Na CHON and Na
LOW
Turn Patient frequently – because pt w/ edema are prone to skin integrity like pressure sore formation
S/S EDEMA: Peri-orbital Edema but subside Periorbital but progresses to generalized at the end of the day end of the day BP :
at the
Decrease or N INCREASE BP
URINE : Frothy colored or Cola colored or Smoky LAB DATA (+) Proteinuria, severe - >10mg in 24 hrs (+) Proteinuria - <10 mg/ 24hrs urine
Tea
CYSTITIS Infection of the bladder Ascending infection caused by E. Coli (from feces) or Pseudomonas RF :
Nsg Dx : Fld Volume Excess Impaired Skin Integrity PI : Check BP Maintain Fld Balance Meds : NO Antihypertensive Antihypertensive (+) Steroids Diuretics (+) Antibiotics
Wearing silk underwear (does not absorb moist); - use COTTON Bubble bath Prolong driving Common in FEMALE – due to size (short) urethra S/S: FREQUENCY, URGENCY & HESISTANCY + Burning sensation on urination (dysuria) LAB DATA :
Urinalysis – to check for microorganism
Nsg Dx :
Altered Elimination Pattern
96 Infection PI :
Treat for Infection – antibiotics for 10-15 days Bladder Analgesic (ex. PYRIDIUM – ch can cause ORANGE COLORED URINE, effective : (-) pain) Diet : ACID-ASH DIET – give lemon juice or VIT C Hx Teachings: Avoid bubble Bath No Silk underwear Inc. Fld Intake RENAL FAILURE ACUTE CHRONIC MP
OLIGURIC PHASE - decrease urine output that is less than 400 ml/24hr (OLIGURIA) There will be INC BUN & Crea - Dec NA & Inc K RENAL FAILURE DIURETIC PHASE - Inc urine output (4-5L/day) All s/s + Anemia & HPN - Dec Na & K ESRD RECOVERY PHASE - renal funx normalizes (1-2 yrs) Azotemia & Uremia – accumulation of waste products
Sudden or Acute, Usually Reversible loss of IRREVERSIBLE kidney damage that Kidney Funx leads to scar formation
“uremic frost” – skin pruritus LAB DATA
There is inability of kidney to maintain fld & E balance Causes PHASES
:
Nsg Dx
Pre-renal Factors – those that dec bld circulating vol. – SHOCK; Phase I: RENAL INSUFFICIENCY Intra-Renal – dses condition of the kidney eg. AGN Post-Renal – those that causes obstruction eg. Kidney stones Polyuria Nocturia Polydipsia Phases of ARF PHASE II : MILD RENAL DAMAGE
Increase BUN and same Crea – most sensitive Index
Fld and E Imbalance Fld & E Imbalance Activity Intolerance PI :
TO CORRECT THE IMBALANCE
A. Fluid restriction; restriction B. Meds : Diuretics Amphogel – to promote excretion of Cardiac Glycosides – Digitalis Phospate
Fld
97 Antihypertensive Inc RBC synthesis C. DIET : Low CHON – NO PMS same
Epogen – Diuretics AntiHPN Diet:
muscle abnormalities – twitching seizures RENAL TRANSPLANT – s/s of complication : FLANK PAIN, FEVER, TENDERNESS, HPN - REPORT
DIALYSIS BPH -
PERITONEAL HEMODIALYSIS
glandular enlargement of the prostrate common in males above 40 yrs old
S/S : Decrease size and force of urinary stream Nocturia Frequency, hesitancy and urgency
Semi-permeable membrane: Abdomen (peritoneum) Dialyzing machine Use of Tenchkoff Catheter fistula or shunt
Use of
LAB DATA: Digital rectal exam – once a yr for pt 40yo and above
Teachings: anastomosis of artery & vein (internal access) – less prone to infxn
Report Infxn (abdomen: rigid, Solution : cloudy) Check BT and CT external access Check Temp of dialyzing solution (more prone to infxn)
Complications of dialysis (report ASAP): DISEQUILIBRIUM SYNDROME – due to rapid removal of solutes (electrolytes and CHON) s/s: GI – nausea, vomiting, headache CNS - convulsion, seizures 1.
2. DIALYSIS ENCEPHALOPATHY – due to aluminum toxicity s/s: (+) dementia
gloves, ky jelly position: Sim’s Nsg Dx :
Altered Elimination Pattern
PI : Prepare pt for surgery TURP – no incision Suprapubic Prostatectomy Retropubic -do Perineal -do- - common complication: IMPOTENCE due to nerve damage “I am eager to have sex again” – cannot be bec pt is impotence nsgcare :
CBR for 2-3 days post
surgery; NO LONG DRIVE/ SITTING; Ff up check up (if INC ACID PHOSPATASE: Prostate CA)
98
TIPS FOR GENITOR-URINARY
A common sign of ARF – OLIGURIA;
After peritoneal dialysis, w/c of the ff is appropriate action – turn pt to side; To prevent cystitis, w/c of the ff the nurse must instruct to the pt to do – take a bath using the shower rather than bubble bath; For early detection of prostrate CA the nurse shld emphasized – digital rectal exam annually to screen for prostrate CA in men 40 yo and above; In a pt with BPH, the nurse shld expect that the pt will probably have the symptoms – residual urine of more than 50 ml; A male pt has an arteriovenous fistula in his L forearm, w/c behavior would indicate that the pt needs further instruction in self care – he wears a watch on his L wrist; w/c of the ff indicates complication of peritoneal dialysis – cloudy dialysate
DAY 8 (Feb 11, 2005) EENT General Consideration Explain to the patient there there will be no or little discomfort when performing EENT exam; Explain the methods of assessment to the patient; Consideration to Pediatric Patients
99 Obtain feeding history (bec the type & techniques differs) Obtain the diet hx of the pt and hx to URTI Involve the parents in the assessment of the baby Reportable Signs and Symptoms TINNITUS - ringing, buzzing or sea shell sound in the
ear
VERTIGO - Objective – “the room is spinning” Subjective – “I feel that I am revolving/rotating”
Hearing Loss Pain – if pain subside or (-) – rupture of ear drum
Absence of pain indicates rupture of Tympanic Membrane – ear drum Lab Data : OTOSCOPY – revealed – reddened, bulging tympanic membrane Nsg Dx :
Infection Sensory – Perception Alteration
PI : Treat Infection (antibiotics – 7-10 days) – if does not heal – possible MYRINGOTOMY Hx Teaching :
RIGHT POSITION while feeding
Keypoints for Assessment
Note for abnormal findings Document the subjective and objective complaints
OTITIS MEDIA
RETINOBLASTOMA
-
FEMALE)
infection of the middle ear
RF : Faulty feeding practices Swimming in dirty waters Upper Resp. Tract Infection S/S : PAIN – Pulling Tugging Crying when lying on the affected ear
congenital tumor of the retina; genetically transmitted; autosomal dominant (common in MALE and
S/S : LEUKOCORIA – “cat’s eye reflex” - whitish or grayish discoloration of the pupil Diplopia and or Strabismus LAB DATA :
PE Opthalmoscopy
100 Nsg Dx :
Knowledge Deficit
Lab Data : Opthalmoscopy
Tx : Surgery – Inoculation – done b4 age of 3 (chemotherapy – after surgery) Genticist
Nsg Dx :
Risk for Injury
PI : Immediate Bed rest – AFFECTED SIDE TOWARDS THE BED – to allow the connection of DETACHED PART
RETINAL DETACHMENT CATARACT RF: Aging (above 40) Aging (above 70) Related to trauma Related to Trauma
GLAUCOMA NO SUDDEN HEAD MOVEMENT AVOID reading (TV – ALLOWED) Aging (above 40)
Prepare Pt for Surgery: SCLERAL BUCKLING – use of laser to reduce inflammation and
Common in Blacks
when inflammation subside, the
Familial Predisposition
Rel. to
Diabetes Rel. to Steroids Rel. to
detached retina portion will be attached thru scar formation.
Chromosomal Abberation - those with D. Syndrome are prone
POST SURGERY : AVOID activity that requires BENDING, LIFTING, COUGHING; (No Bowling & shampooing of hair at sink)
RETINAL DETACHMENT MP : There is separation of sensory and pigment portion of the retina – therefore it will allow fluids to go in between which give rise to OUSTANDING manifestation as:
REPORT SUDDEN eye pain – indicative of bleeding/ hemorrhage
VISUAL FLOATERS – pt says: “I see light structures Curtain like Floating spots Cobwebs” S/S : NO Pain Blurring of vision – because of floaters
GLAUCOMA MP : INCRASE IOP due to obstruction in the outflow of acqeous humor or could be related to forward displacement of the iris. TREATABLE but NOT CURABLE
101 If Obstruction related : OPEN ANGLE.
could lead to CHRONIC
If due to Forward displacement: can lead to ACUTE CLOSE ANGLE
b. Prepare pt for Surgery : TRABECULOPLASTY – a new pathway was created for the passage of the blocked fluids; - Out-patient only (use of laser only) TRABECULECTOMY – requires hospital admission for 1-2 days
S/S : TUNNEL or Gun Barrel Vision – wherein there is loss of Peripheral Vision
Hx Teachings : same w/ retinal detachment
Halos around lights – rounded rings around eyes CLOSED ANGLE GLAUCOMA – (+) pain OPEN ANGLE GLAUCOMA – minimal or (-) pain LAB DATA:
Tonometry – measures IOP (N12-21) – PAINLESS
ACUTE G Chronic G
– as high as 25; - as high as 50 Gonioscopy Opthalmoscopy Perimetry – measures visual field
CATARACT MP : Opacity of the Crystalline Lense S/S :
Blurred Vision (Poor Color Perception) NO PAIN
LAB DATA: Nsg Dx : PI :
Risk for Injury
TO DECREASE IOP How:
a. Administer MIOTICS (Pilocarpine, Tomolol, Diamox) – for LIFE it decrease the production of ACQEOUS HUMOR – admin. At lower conjunctival sac
a.
SLIT LAMP TEST – test for red light reflex (this reflex is absent in cataract pt due to presence of milky white lens) b.
Opthalmoscopy
Nsg Dx : PI :
Risk for Injury
Prepare for SURGERY
102 CATARACT EXTRACTION – Extra Capsular Cataract Extraction (ECCE) Intra Capsular Cataract Extraction (ICCE)
Hearing Loss + VERTIGO (only for M. DSES) Lab Data:
same
Caloric Stimulant test Weber’s test –
ECCE – removal of anterior part
lateralization of sound Rinne’s – bone
ICCE – removal of entire capsule
conduction Audiometry (above test –
PHACOEMULSIFICATION - needle is inserted to lens and send vibration thereby crushing the cataract then suction it out
use of TUNING FORK)
PERIPHERAL IRIDECTOMY – a whole is created then suctioning
Nsg Dx : Risk for Injury Perceptualalteration
Sensory
PI : SAFETY Communication (to prevent pt from falling: bedrest or supine – danger of falls) Surgery : STAPEDECTOMY – mobilization of
Establish
Post Cataract Surgery – NO SEX for 4-6 weeks Health teachings – same w/ R. Detachment MENIERE’S DSES
OTOSCLEROSIS (hardening
stape
of the ears) RF :
High altitudes Aging Ototoxic Drugs
Aging
S/S : Tinnitus
LOW NA (AVOID – Alcohol & Caffeine containing
Meds : AntiVertigo – Diamox, Bonamine Post Surgery Hx Teachings:
MP : Cause by an imbalance of EndoOvergrowth of the stapes Lymphatic Fluids in the inner ear Sensori-neural hearing loss – since Conductive Hearing Loss Inner ear was affected middle ear was affected
DIET : food)
Effective : (-) Vertigo/ Falls
AVOID – diving Small
airplane - since
same
Coughing AVOID - driving Blowing of Nose PMS Sudden Head Movement
Bending
103
TIPS FOR EENT A pt who underwent cataract surgery w/ intraocular implantation is scheduled for discharge, the nurse shld instruct the pt to do w/c of the ff when pain occurs – notify the AP; GASTROINTESTINAL
w/c Nsg Dx is considered a priority for a pt with Meniere’s Dses – Risk for Injury a Tonometer is used for the purpose – to determine IOP; Post Cataract Extraction : how shld the nurse position the pt – UNAFFECTED SIDE to minimize edema; w/c of the ff is a common Retinoblastoma – Cat’s Eye Reflex;
manifestation
of
The parents of the pt w/ retinoblastoma must be referred to - GENETICIST
GENERAL CONSIDERATION Provide privacy Ask the pt when he 1st notice the S/S Eg. LIVER CIRRHOSIS – when did you notice that your eyes turns yellow?
PEDIATRIC CONSIDERATION
Introduction of FOOD: (shld be in order)
Cereals Fruits Vegetables Meat Table foods Obtain child Dietary History Assess for over-intake of milk – poor source of iron (IDA) REPORTABLE S/S Vomiting Abdl Pain (if more than 6hrs) – R/O rupture of the bowel
104 Tarry Stool – indicates bldg (upper GI) Fever, Tachycardia, Dehydration – indicative of SHOCK Hypotention KEPOINTS… Bowel Sounds (check all 4 quadrants- N 5-35 bowel sounds/min) to assess, use DIAPHRAGM of Steth – to listen for normal sounds BELL part of Steth – to listen for abnormal bowel sound
Nsg Dx : Diarrhea Fluid Volume Deficit PI : Place pt on ENTERIC ISOLATION PRECAUTION (handwashing & gloves ONLY) – while waiting for lab result
CHALASIA
GERD
Ex. “bruit” – abnormal vascular sound w/c indicate abdml aortic aneurysm
SPHINCTER
DIARRHEA/ AGE
S/S: vomiting - NON-BILE-STAINED burn due to Reflux of Acid
- usually asso w/ NORWALK (common in ship), ROTAVIRUS and CLOSTRIDIUM DEFFICELE MP : Passage of watery and loose stools (BEST judge in the consistency) S/S : Frequent stools Sign of DHN – sunken fontannels Poor Skin Turgor Absence of Tears (for more than 2 MONTHS old infant) Check for complication : Metabolic Acidosis If excess fluid loss, it will progress to shock – due to K loss (hypokalemia)
CONGENITAL WEAKNESS OF THE CARDIAC
Complication : METABOLIC Acidosis same BARRETT’S ESOPHAGUS same - damage to mucosal lining of lower esophageal mucosa w/c can lead to esophageal CA
LAB DATA : Upper GI Series (Ba Swallow) Gastroscopy Esophagoscopy
Stool Exam – to check for bacteria
do do do
Nsg Dx : Altered Nutrition Less Than Body Requirement Flds & E Imbalance PI :
LAB DATA :
Hear-
Insure Adequate Nutrition Position: Place pt in UPRIGHT – to avoid vomiting
105 (if BABY: use HARNESS or PRONE w/ HEAD UP POSITION) Administer flds Antibiotics/ Antidiarrheals ( dosage: if less than 10 kg, therefore X100) Health teachings – crackers, juice, water Feeding : Thickened Prepare pt for surgery : NISSINFUNDOPLICATION – part of fundus will be sutured to
NON-CORROSIVE – induce vomiting by stimulating GAG REFLEX How: a. Use fingers or tongue blade b. Syrup of Ipecac – administer w/ glass of H2O – make sure that all taken will be vomited – bec it is cardiotoxic (after 1hr – can repeat) dosage: ADULT
esophageal area to tighten Effective: if (-) vomiting and(-) reflux and heartburn
CHILDREN – 15 ML - 30 ML CLEFT
LIP POISONING INTERVENTION: a. b. c.
CALL poison control center; MINIMIZE EXPOSURE – remove pt from the scene IDENTIFY the type of poison
“if unknown substance was taken” – bring bottle or foil for proper identification
MP: Non-fusion of facial process Palative Processess (soft & hard) (congenital) Nsg Dx :
Altered Nutrition Risk for Aspiration Body Image Disturbance
PI :
Nutrition Safety Prepare for Surgery
TYPES:
CORROSIVE – “DO NOT INDUCE VOMITING” Management: NEUTRALIZE the poison If STRONG ACID – give WEAK BASE (eg. ACID –
give MILK) IF STRONG BASE – use weak ACID by using vinegar
PALATE
Surgery : Chiloplasty Uranoplasty - for 10wks old 18 mos 10 lbs 10gms/hgb 10,000 WBC Post Surgery:
Non-fusion of (congenital)
Palate - if child is 15-
106 CRYING shld be minimize – bec it will put pressure at suture line; LOGAN BAR/ BOW – it decrease tension at suture line; ELBOW RESTRAINT – prevent child from touching the suture line; FEEDING DEVICE – C CLIP – use dropper, C PALATE – use Breck Feeder/ cup Refer pt to: SPEECH THERAPIST, AUDIOLOGIST & PSYCHOLOGIST
PYLORIC STENOSIS congenital hypertrophy (“kumapal”) of the pyloric sphincter (bet stomach & intestine) S/S :
PI :
Nutrition Surgery – FREDET-RAMSTEDT or PYLOROMYOTOMY – incision at pyloric sphincter
CELIAC DISEASE -
GLUTEN –INDUCED ENETEROPATHY Genetic predisposition Life-time disorder
MP :
PROJECTILE VOMITING (INITIALLY, NON-BILE STAINED but eventually it PROGRESSESS TO bile-stained) If sitting : 4-5 ft If lying down : 1 foot Feeding should be thickened then AFTER FEEDING, place to RIGHT SIDE LYING SEATED at car seat – to facilitate the entry of food from stomach to duodenum OLIVE-SHAPE MASS VISCIBLE PERISTALTIC MOVEMENT – usually from L to R of the abdomen – w/c can lead to DHN LAB DATA : Ba Swallow – (+) “string sign” NSg Dx :
Fluid Vol Deficit Fld and E imbalance
Altered Nutrition
Intolerance to GLUTEN
OUTSTANDING S/S : Malabsorption Syndrome-crisis Abdl Enlargement – this can be triggered by INFECTION & Fld and E imbalance Anorexia Anemia - there will be SEVERE DHN LAB DATA : Diagnostic Test : GLUTEN CHALLENGE – 3-4 mos – give gluten rich food And if there is malabsorption, therefore (+) CDses Nsg Dx :
Altered Nutrition
PI : Dietary Modification : FOOD : Barley, rice, oats, wheat
AVOID GLTUEN RICH
ALLOWED : Rice, cereals, corn, soy beans
107 Commercially prepared cakes are made of wheat – AVOID Ok or allowed: if pt say “I will prepare a homemade cake” AVOID : spaghetti, macaroni, sausage, luncheon meat, hotdog INTUSSUCEPTION HIRSCHPRUNG’S DISEASE (AGANGLIONIC MEGACOLON)
MP : There is telescoping of a part of a colon which leads to inflammation and edema
MP : Absence of parasympathetic nerve fibers in a portion of a colon dilation, abdominal distention and pellet-like or ribbon-like stool.
S/S : “sausage-shape mass” Abdominal distention “Dance sign” – the R lower portion of the colon becomes empty Vomiting : BILE-STAINED Constipation LAB DATA : Ba Enema: if for DIAGNOSTIC : it outlines the area involve if for THERAPEUTIC : it reduces intussuception by means of hydrostatic pressure
Patient – meconium ileus & constipation – HALLMARK SIGN LAB DATA : BA Enema Nsg Dx :
Altered Ellimination
Diet :
High Fiber Increase fluids
Tx :
Give Enema
Nsg Dx : Diet : Meds :
Laxative Surgery – SOAVE Surgery – resection with end to end pull through
Tx :
Constipation Altered Elimination Inc. Flds. High Fiber wonder drugs – steroid surgery
TRACHEOESOPHAGEAL FISTULA (TEF)
108 MP : Failure of the esophagus to develop as a continous process Types : AF1 esophagus NOT connected w/ abdomen/stomach AF2 esophagus attached to trachea (when pt eat, it goes to the lungs) AF3 stomach connects w/ trachea AF4 stomach & esophagus connected AF5 stomach, eso and trachea are connected AF6 separated properly Atresia – “narrowing” Fistula – connection S/S : Excessive Drooling – danger in aspiration (avoid glucose water as initial feeding – use sterile H2O instead.) Coughing, Chocking Cyanosis LAB DATA :
Lateral Neck Xray – to check the esophagus
Nsg Dx :
Risk for Aspiration
PI :
Safety Airway Keep child NPO – just give pacifier (if feeding OK – use sterile H2o instead NOT GLUCOSE) Tx :
Surgery
TIPS FOR GASTRO – PEDIA w/c of the ff signs if manifested by a child post tonsillectomy needs to be reported – FREQUENT SWALLOWING; a child who has had several episodes of diarrhea is likely to develop – metabolic acidosis; in relation to dx of p. stenosis, w/c of the ff actions of the nurse is important – weighing pt daily for wt loss; w/c of the ff will the nurse expect to observe in a child who loss fluid due to diarrhea – flushed dry skin; the most appropriate feeding device for a child post cleft palate – paper cup; the priority nsg care for a child on NPO is – offer a pacifier regularly; a common manifestation of pyloric stenosis is – visible peristaltic wave; the priority nsg dx for a pt w/ rotavirus infection is – diarrhea; w/c of the ff is expected in a child suffering from celiac dses – intolerance to gluten
PEPTIC ULCER
109 RF :
Stress Smoking Salicylates or NSAIDS Helicobacter Pylori Zollinger-Ellison Syndrome (gastinoma) – tumor of the stomach – due to increase HCL acid GASTRIC DUODENAL RF :
Nsg Dx :
PAIN
PI :
Relief of Pain
ESOPHAGEAL
same
Meds : ANTACIDS: Maalox – it NEUTRALIZE HCL Acid; RANITIDINE - it DECREASE HCL Acid; SUCRALFATE - it COATS the GIT
same
MP : Weakened Mucosa Excessive HCL Acid Common in Female in Male Below 65 above Inc risk for CA
Common 65 yo &
NO ASPIRIN Diet : vegetables
BLAND DIET – NO SPICY, fried, raw fruits and (EXCEPT: avocado, banana &
pineapple) OUSTANDING S/S: PAIN – aching, burning, gnawing
GASTRIC SURGERY
PAIN – 30mins – 1hr post meal 3hrs after meal PAIN at daytime Nightime Pain relieved by vomiting Pain relieved by eating
2-
Also related as hyperacidity HEMATEMESIS (vomiting of blood) - severe bleeding – “shock” LAB DATA : GASTRIC Analysis (diamox blue – urine) Gastroscopy BA Swallow HgB Hct
(BII)
VAGOTOMY PARTIAL GATRECTOMY – Billroth I (BI) and Billroth II TOATAL GASTRECTOMY
BI – gastrodoudenostmy – duodenum and stomach BII – gastrojejunostomy – stomach and jejunum COMPLICATIONS: PERNICIOUS ANEMIA – due to decrease INTRINSIC FACTOR w/c came from stomach;
110 DUMPING SYNDROME (occur usually for 10-12 mos post surgery) – due to rapid emptying of the stomach and stimulation of gastro-colic reflex GASTRO-COLIC REFLEX – is usually due to increase CHO INTAKE in the diet - NO PANCAKE, NO UPRIGHT SITTING AFTER MEALS S/S OF Dumping Syndrome : Diarrhea Diaphoresis Dizziness/drowsiness Management: NO FLUIDS after meals – instead in between meals DIET: High Fats – because it delays the emptying of the stomach LOW CHO Lie down – after eating
MP : Inflammation @ large Intestine Inflam @ L Intes. – Inflam of small & Specifically @ recto-sigmoid colon at DIVERTICULUM large intestine S/S :
same same
DIARRHEA (15-20x/day) 3-4x/day bloody mucoid
diarrhea & constipation
FEVER
(+)
(+) (+)
CRAMPY ABDL PAIN LLQ LLQ RLQ (Rigidity (REPORT ASAP) –sign of colon rupture) LAB DATA: BA ENEMA Colonoscopy Stool Exam
INFLAMMATORY BOWEL CONDITION
ULCERATIVE COLITIS CROHN’S DSES
Nsg Dx :
PAIN Altere Elimination: Diarrhea
DIVERTICULITIS
(Regional Enteritis) RF : With familial Predisposition Common in those LOW FIBER Diet Related to Genetics Smoking as Protective Effect Common in Aging Common in Obsessive-Compulsive Or Stress Related or to “perfectionist”
PI :
Relieve Pain Meds: Steroids Anticholinergic Antidiarrheals Antispasmodic
DIET : Low Fiber and Low Residue – for Ulcerative and Chron’s
111 Diverticulosis – High Fiber/residue – allowed: vegetables Low residue – (no vegetables)
III Entire Area – manual reduction IV Entire Area – irreducible TYPES
SURGERY : Colostomy – irrigate Ileostomy – no need for irrigation
INTERNAL H – above the spinchter EXTERNAL H – below the spinchter
Characteristic of N Colostomy – REDDISH or PINKISH EDEMATOUS MOIST N elevation from skin: 2.5 cm Diameter : 5cm
S/S
LAB DATA
Sigmoidoscopy Proctoscopy P Exam
When to empty colostomy: when 1/3 – ½ full (EMPTY DO NOT CHANGE)
Nsg Dx
Altered Elimination
PI
Diet : High Fiber Avoid Spicy
When to change C. Bag : 48hrs or 3x a wk
Pruritus Pain Bleeding
BEST TIME TO DO COLOSTOMY CARE – at home, while in the bathroom
PAIN – use SITZ BATH (48 degree C – temp of H2o)
STOP colostomy irrigation if patient (+) ABDOMINAL CRAMPS
- emerge up to pelvic area with ice pack at head to prevent dizziness STOOL SOFTENER SURGERY
HEMORRHOIDS MP
Varicosities of the ANAL SPINCHTER
RF PREGNANCY PROLONGED STANDING PORTAL HPN – hepatic enceph and liver cirrhosis
PANCREATITIS AUTODESTRUCTION OR AUTODIGESTION of the pancreas RF
GRADE I Small Area II Large Area – reduces spontaneously
#1 Alcoholism #2 autoimmune High Fat Diet Biliary Dses
112 SS PAIN @ peri-umbilical area or epigastric that radiates to peri-umbilical area GREY TURNER SIGN – pain w/ bluish discoloration at flank area; CULLEN’S SIGN – pain w/ bluish discoloration @ umbilicus
Forty flatulence S/S R UQ Pain radiating to R shoulder or R Scapula – usually precipitated by FATTY INTAKE GI S/S – NAV diarrhea and Jaundice URINE: dark colored
NAUSEA & VOMITING SHOCK – as complication
STOOL : “clay-colored” or grayish – alcoholic stool
LAB DATA Elevated Serum Amylase (N56-190 u/L that normalize in 2 wks) Nsg Dx PI
Increase AMYLASE, WBC, FATS Increase Liver Fnx test USG
Nsg Dx
PAIN
PI
Relief of Pain meds : DEMEROL diet: LOW FAT
PAIN Relieve PAIN
Meds: DEMEROL – DRUG OF CHOICE AVOID MORPHINE – it causes more pain bec it will causes spasm to the spinchter of oddi DIET
LAB DATA
surgery : incision, CO2 insufflation
LOW FAT AVOID alcohol
1) LAP. CHOLE – 4 small
2-3 days after – discharge pt and back to ADL 1 WK after – pt can lift weight CHOLELITHIASIS
CHOLECYSTITIS
Combine or usually come together in a pt
2) CHOLECYSTECTOMY – R SUBCOASTAL complication: “Pneumonia” – report rusty-colored sputum hx teaching:
Stone in gall bladder Inflammation of the G. bladder RF
Fat Female Fertile
TURNING, COUGHING, DEEP BREATHING same
113 HEPATITIS MP
Isolation : A & E – Enteric B, C, D – Universal
Inflammation of the Liver COMPLICATION Liver Cirrhosis
TYPES A
B
C
D
E
Infectious SERUM POST TRANSFUSION DELTA HEPA ENTERICALLY-TRANSMITTED
LIVER CIRRHOSIS - scarring of liver tissues TYPES
Fecal-oral bld, body flds Post Hepa B Fecal-oral
Non A & B
(Hepa A & B Combination 2-6 wks 6wks-6mos 70-80 days 6mos
LAENNE’S NECROTIC 6wks-
STAGES OF HEPA B
PRE-ICTERIC - 1-2 days : S/S NAVDA – NO jaundice yet; ICTERIC - 2-4 wks w/ jaundice; POST ICTERIC - 2-4 mos s/s subside
Lab data
Increase Liver Funx Test (Inc AST/ ALT) Hepa A – Inc HaV Hepa B – HbsAg
Nsg Dx
Infection Alt Skin Integrity Body Image Disturbance
BILIARY
Due to alcoholism CHF due to Hepatitis
CARDIAC
Due to biliary Disorder
POST due to
S/S – are related to 3 FUNXs of the LIVER MANUFACTURES : bile, immunoglubolin, & clotting factors METABOLIZES: CHO, Fats, CHON, Alcohol and Drugs STORES : Vitamins & Minerals Signs and symptoms
PI
Tx for Infection a. Meds : HEPATOPROTECTORS DIURETICS
a. b. c. d.
pt prone to bleeding; malnutrition – no cho metabolize edema – due to fld retention (bec of dec albumin) Flds & e imbalance
LAB DATA b. Diet : High Calorie Low Fat
Increase Liver Funx Test Liver Biopsy
114 Nsg Dx
Risk for Injury Fld & E imbalance Fld Vol Excess Altered Nutrition
PI
SAFETY HOW?
Meds: Diuretics – due to fld retention ANTIHPN – due to portal HPN Clotting factors : Coagulants – give Vit K (to avoid bleeding)
Increase abdl girth – “I cannot button my pants anymore” (fluids) management: abdominal paracentesis – aspiration of fluids from the peritoneum - complication: chance for infection & shock
Diet : LOW CHON or CHON to Tolerance Or High Biologic Value CHON – good quality CHON (eg poultry products)
SURGERY :
Liver Transplant
COMPLICATIONS: a. HEPATIC EBCEPHALOPATHY – accumulation of ammonia – toxic to brain s/s:
PERSONALITY CHANGES DECREASE LOC or irritability/ restlessness
DRUG OF CHOICE : Neomycin, Lactulose - facilitate excretion of ammonia by acidifying the colon - common s/e : DIARRHEA b. s/s :
ASCITIS – accumulation of fluids at the abdomen wt gain
pt preparation: #1 instruct pt to void; #2 position: sitting the evaluate the WEIGHT, ABDL GIRTH & REPSIRATION effective if : Pt decrease wt of 5 lbs and decrease or N RR c. HPN
BLEEDING ESOPHAGEAL VARICES – DUE TO portal
Lab data Sengstaken Blakemore Tube – 48 hrs inflated, scissors at bed side (Balloon Tamponade) - effective if (-) hematemesis
115 TIPS GASTRO – ADULT A pt w/ appendicitis was admitted, of ALL the ff written orders, w/c shld the nurse prioritize – Administration of Antibiotics; w/c statement if made by a pt w/ cirrhosis is a risk factor for having the disease – “I drink 2 glasses of alcohol /day”; which of the ff indicates a ruptured appendix – absence of pain; ff subtotal gastrectomy, the nurse shld expect gastric drainage for the 1st 12 hrs to be – reddish brown; the priority nsg care post common bile duct exploration – preventing hypostatic PNA; w/c question during nsg assessment would confirm the Dx of L Cirrhosis how long have you noticed the white in your eyes turns yellow; the priority nsg dx for a pt w/ Hepa B – altered Nutrition the priority nsg dx for for pt w/ acute pancreatitis – Altered nutrition less than body requirements
NEUROLOGY DECORTICATE – abnormal FLEXION DECEREBRATE – abnormal EXTENSION Opistotonous – “back arching” GENERAL CONSIDERATION When assessing the neurological system, pay attention to the ff:
#1 LEVEL OF CONSCIOUSNESS
116
#2 BEHAVIOR #3 REFLEX
When assessing MUSCULO SYSTEM:
#1 Range of Motion #2 Joint Stiffness #3 POSTURES
e. CONTUSSION – more severe, fatal and could even lead to death CONCUSSION – jarring of the brain, “na-alog” w/c could lead to s/s of LOC in 24-48 hrs DECORTICATE – abnormal flexion which indicates damage to the cortex s/s :
PEDIATRIC CONSIDERATION a. Check for bowel and bladder funx – indicates neurological maturity 15-18 months – START BOWEL TRAINING 2 yo – start bladder training
#1 Decrease LOC #2 widening pulse pressure (increase systolic BUT diastole is N) #3 Convulsion & seizures ABOVE ARE S/S OF INCREASE ICP. DECEREBRATE – more serious - abnormal extension w/c indicates damage to brain stem
b. Assess for their habits “security blankets” – ex. Stuff toys, mother wallet Associate mother’s time w/ child activity (children has NO DEFINITE TIME) Ex. Your mom will be back after you have eaten your lunch. c. Assess for presence of URTI – could be sign of Meningitis, Hemophilus influenza, Otitis Media d. Assess child for S/S of anxiety -
bed wetting nail biting (N up to 4 yo) head banging excessive thumb sucking
GLASGOW COMA SCALE EYE OPENING (4) MOTOR (6)
VERBAL RESPONSE (5) 6–
OBEYS COMMAND 5 – ORIENTED LOCALIZES PAIN 4 – OPEN SPONTANEOUSLY CONFUSED 4 – WITHDRAWS FROM PAIN 3 – OPENS TO VERBAL COMMAND INAPPROPRIATE 3 - DECORTICATE RIGIDITY 2 - OPEN TO PAIN 2 - INCOMPREHENSIBLE DECEREBRATE RIGIDITY 1 - NO RESPONSE 1 - NO RESPONSE RESPONSE
54– 3– 21 - NO
117 AND MOTOR : ability of pt to chew SCORE OF 3 : the one to pronounce
NO response (DEAD) – Doctor will Reflex: CORNEAL REFLEX – (+) if both eyes can blink
SCORE OF 15
:
pt is
awake Score of 8
:
7 and BELOW
50-50, MONITOR THE PT :
VII. FACIAL : SENSORY : sense of taste @ anterior 2/3 of the tongue
pt is COMA and MOTOR
CRANIAL NERVES I.
OLFACTORY : SENSORY Abnoxious smell
: Facial Expression
VIII. ACOUSTIC or VESTIBULOCOCHLEAR - Sense of hearing and balance
: smell
-
TEST : ROMBERG’S TEST stand erect, close eyes, observe for balance
Anosmia – no smell Perfume II . OPTIC : SIGHT – snellen’s chart – 20/20 usually by age 3-6 yo
IX. GLOSSOPHARYNGEAL X. VAGUS SENSORY – Posterior Taste 1/3 Of The Tongue MOTOR - swallowing and
III. OCCULOMOTOR IV. TROCHLEAR Eye movement - 6 cardinal direction of gaze VI. ABDUCENS (if abnormal look for DIPLOPIA)
gag reflex XI. SPINAL ACCESSORY - motor movement of shoulder muscle XII.
V. TRIGEMINAL : SENSORY : FACIAL SENSATION
responsible for (to check,
use cotton & needle and run across the cheek)
HYPOGLOSSAL – TONGUE MOVEMENT
118 DUCHENE’S MUSCULAR DYSTROPHY (DMD) X –linked RECESSIVE (only mother transmit to SON)
COMPLICATIONs young children
Respiratory Paralysis – for Cardio-Resp. Arrest
-
for
adolescent (-) Father
Mother (+ carrier) Son - 50% chance LAB DATA
Muscle Biopsy PExam
Nsg Dx
Ineffective Breathing Pattern Impaired Physical Mobility
PI
AIRWAY (keep TRACHEO at bedside)
Daughter as Carrier – 25% chance DMD
Erb Duchenne’s Paralysis (EDP) Klumpke Palsy (KP)
Related to Birth Injuries affecting the BRACHIAL PLEXUS – nerves at axilla portion HEREDITARY
EDP – upper plexus KP - lower plexus
w/c leads to
TX a. b.
Supportive - leg brace, crutches Refer parents to geneticist
paralysis. Prognosis : complete recovery in 3 months
Target: Mothers or FEMALES – bec they are the source of transmission
Treatment : splint and cast for 3 mos – leads to nerve
Ex. Aunt, Female Sibling, mothers, female members of the family – (bec transmission: X linked recessive)
regeneration X-linked RECESSIVE DIRORDER CEREBRAL PALSY MP
S/S
characterized by progressive muscle atrophy w/c apparent in male at the age of 3
- Permanent, Fix (non-progressive) neuromuscular disorder characterized by abnormal muscle movement.
a) GOWER’S SIGN – inability to stand up - use arms to brace the body
Cause
b) WADDLING GAIT - duck-like gait
S/S
c) impaired mobility d) difficulty in running and climbing
Unknown
Exaggerated Reflexes Protrusion of the tongue or tongue thrusting Early pattern of hand dominance Back Arching Scissors-gait
119 LAB DATA
Neurological Assessment PExam
Nsg Dx
Risk for Injury Impaired Physical Mobility
From Lateral Ventricle it goes to Foramen of Munroe then to 3rd Ventricle then to Aqueduct of Sylvius then it moves to F. of Luschka and Magendie going to 4th Ventricle then it goes back to subarachnoid spaces of brain. S/S OF HYDROCEPHALUS
PI
SAFETY
a. Leg braces b. Meds : Anticunvulsants, Muscle Relaxants c. Prepare child for SURGERY – release of TENDON OF ACHILLES – to promote mobility d. Refer child to : PT – for gross motor movement – walking OT - for fine motor – to open a bottle of soft drinks
PROJECTILE VOMITING IRRITABILITY ENLARGED HEAD – N Head Circumference : 3335 cm (chest circum: 31-35 cm) SEPARATION OF SKULL BONES SEIZURES SUNKEN EYES – Can Progress To Bossing Sign MACEWEN SIGN – crack pot sound upon knocking the head LAB DATA
HYDROCEPHALUS NOT A DISEASE but a manifestation of an existing disorder
CT Scan MRI PExam – focus on head circumference (tape measure – at bedside measure H Circumference) NSG DX PI
Related to ARNOLD CHIARI MALFORMATION DANDY WALKER SYNDROME there is ELONGATION of the BRAIN STEM or Medulla - characterized by ATRESIA of and it protrudes to Foramen magnum Foramen of Luschka & Magendie SIDE NOTES: rich in glucose
FLOW OF CSF (N amt : 100- 200 ml) –
Position in ICP Meds
to
Risk for Injury SAFETY Semi Fowler’s – to prevent increase Diuretics Anticonvulsants
Surgery Ventriculo-Peritoneal progressive procedures
Shunt
– (AS
CHILD AGE PROGRESSES, the surgery is revised)
120 Meningocele
–
w/
sac that contains CSF and meninges; Meningomyelocele – CSF, meninges and portion of spinal nerves LAB DATA Amniocetesis – test for ALFA FETO CHON – if INCREASE – Neural Tube Defect If DECREASE – Down Syndrome CT SCAN PExam NSG DX
Risk for Injury
PI
Protect the sac
a. b. c.
Position: Prone or side lying (NEVER SUPINE); Wet sterile gauze to cover the skin; DOUGHNUT ring
SURGERY
WITHIN 24-48 HRS
SPINA BIFIDA – failure of a PORTION of spinal cord to fuse
COMPLICATION
TYPES
Post Surgery Complication measure- at bed side)
SB OCULTA NO SAC W/ DIMPLE or TUFT OF HAIR
Bladder and Bowel Problem Paralysis of Lower Extremities Hydrocephalus (tape
SB CYSTICA W/ SAC
INCREASE ICP
SUB TYPES:
ICP above 15mmhg (N 0-10) Mild elevation : 11 – 20 Moderate : 21 - 30
121 Severe
: 31 and above
With the use of INTRAVENTRICULAR or SUBDURAL MONITORING DEVICE to monitor ICP RF
MENINGITIS MENINGISMUS
Hydrocephalus Space Occupying Lessions Brain Tumor Trauma
Inflammation of meninges w/c could be related to Inflammation of meninges but WITHOUT the presence of bacteria esp the H. Influenza, and infection Neisseria Meningitidis Usually accompany w/ resp. disorder
S/S 1. INITIAL: Behavioral Changes – irritability, restlessness, decrease LOC – drowsiness or pt becomes sleepy 2. Vital Signs Changes – widening pulse pressure DECREASE RR and PR INCREASE temperature
S/S of INC ICP + Kernig’s Sign – pain on extension of lower extremities + Brudzinkis - flexion of neck would lead to flexion of lower ext. - sign of MENINGEAL IRRITATION LAB DATA
Lumbar Puncture CSF Analysis
Nsg Dx
Infection Risk For Injury
PI
Safety Seizure Precaution Tx the Infection
3. Vomiting 4. Monitor Abnormalities – decorticate, decerebrate
Nsg Dx PI
Risk for injury To decrease ICP
Head of Bed ELEVATED Evaluate Neuro Status – Glasgow AIRWAY Discharge Meds Instruction Anticonvulsants, Steroids, Diuretics (mannitol – to dec amt of cerebral edema) Seizure precaution – DARKENED ROOM
Type of Infcetion: a. b.
Bacterial Meningitis – respiratory of droplet precaution Viral Meningitis - enteric precaution
MEDS Antibiotics For Bacterial Meningitis - may cause hearing impairment - refer to AUDIOLOGIST
122
REYE’S SYNDROME
CVA/ STROKE
Non inflammatory, non recurring but TOXIC ENCEPHALOPATY and HEPATOPATHY (CNS)
(LIVER)
RF
Presence of Viral Infection Use of Aspirin
TRIAD S/S Fever Impaired Liver Funx Impaired Consciousness w/c could lead to convulsion STAGES
I II III IV V
pt becomes lethargic confusion decorticate rigidity decerebrate rigidity seizure or coma
LAB DATA
Bleeding and Clotting Time Liver Biopsy Neurological Assessment
Nsg DX
Risk for Injury Altered Thought Process Altered Thermoregulation Impaired Physical Mobility
PI
Treatment – symptomatic – assess neuro
status Bleeding – give Vit K AVOID ASPIRIN when there is VIRAL INFECTION
MP
Decrease Oxygen to brain cells
TYPES THROMBOSIS EMBOLISM HEMORRHAGE INFARCTION RF atherosclerosis hpn obesity smoking stress age/ gender SIGNS & SYMPTOMS: 1. DEPENDS ON THE PROGRESSION
a. TIA – brief period of neurologic dysfunction that last less than 24 hrs (between episode, pt is N); b. STROKE IN EVOLUTION – there s/s like: facial paralysis Muscle weakness - above s/s could last 2-3 days c. COMPLETE STROKE – there is FOCAL s/s if R side of Brain Affected – L Eye - R Face – L Body if L Brain – R Eye – L face – R body 2. RELATED TO LOBES
123 FRONTAL – if affected – PERSONALITY CHANGES – BROCA’S AREA (expressive aphasia – mouth opening);
TEMPORAL - memory disturbances – WERNICK’S LANGUAGE AREA (choice of words, understanding - RECEPTIVE APHASIA); PARIETAL - DISORIENTATION – especially SPATIAL orientation;
mgt: talk to pt slowly Dysphagia swallow twice to prevent aspiration
instruct the pt to
LAB DATA
Increase Cholesterol
Diagnostic Test
CT Scan MRI EEG
OCCIPITAL - VISUAL disturbances Nsg DX care half of the body
Unilateral Neglect – inability to Impaired Physical Mobility Risk for Injury
PI
3. SIGNS AND SYMPTOMS INDICATIVE OF COMPLICATIONS Hemianopsia loss of half of the visual field (eg. Pt consumes half of the food at plate); Hemiphlegia
paralysis of one side “mood swing”
Aphasia Expressive – inability to find right words to say (damage to Brocka’s Area); - pt can say right words – mgt: picture board and Receptive inability to understand spoken words (Wernick’s area)
Position
Semi-fowler’s Elevated
Meds
Antihypertensive Diuretics Antilipimic Agents Anticonvulsants Thrombolytics – if (+) thrombus –
to dissolve clots DIET
of the body; Emotional Lability
SAFETY
Low Na and Cholesterol
Activity
Range of Motion Exercises
Surgery
Craniotomy Infratentorial Cranio – FLAT Supratentorial - Semi-
fowler’s
124 DISEASES OF NEUROMUSCULAR Barre Syndrome (GBS)
:
Guillain
LAB DATA CSF – Increase CHON TENSILLON TEST – 5 mins (to all neuromusco disorders)
Myastenia Gravis (MG) Multiple Sclerosis (MS) Amyotrophic Lateral Sclerosis (ALS) GBS MG
Descending paralysis – start @ upper ext. Common in Male and Female NO gender related factor but could be related to viral infxn Early onset : 20-30 yo (Female) Reversible Early onset : above 50 yo (male) MP Inflammation that leads to destruction of Peripheral Nerves Deficiency in ACTH Receptor Sites – 90% w/c leads to: ASCENDING GBS Or Def. in ACTH – “neurotransmitter” DESCENDING GBS Mixed Type GBS ASCENDING GBS - #1 Clumsiness that eventually lead S/S Muscle weakness w/c begins at face muscle weakness & resp. depression therefore, Diplopia and Ptosis – which
Nsg Dx Ineffective Breathing Pattern (ALL) same PI AIRWAY (tracheostomy – bed side) – ALL same MEDS Steroids Neostigmine – ATSO4 - antidote Avoid crowded areas : viral infection Refer to NEUROLOGIST, PULMOLOGIST and PT MYASTHENIA GRAVIS COMPLICATIONS Myasthenia Crisis (MC) - due to under medication or lack of meds; Cholinergic Crisis (CC) - due to over medication – overdose Signs and symptoms of above complication: MUSCLE WEAKNESS – in MC due to ACTH Deficiency while in CC due to or as adverse effect of the drug
to
progresses to MASK-LIKE face which lead to respiratory depression (descending paralysis – start at face – “NO telebabad”)
Treatment : TENSILLON – effective in MC – it INCREASE MUSCLE STRENGTH Effect in CC – it worsens muscle weakness once given – give ATSO4 NEOSTIGMINE – for MC as TREATMENT
125 (LON GAHRIG’S DISEASE) MULTIPLE SCLEROSIS Common among women – especially white There is destruction of MYELIN SHEET at CNS , therefore generalized muscle weakness
MP
Destruction of Upper and Lower Motor Neurons; Genetically Transmitted: AUTOSOMAL DOMINANT – common in Male & Female More Pronounce is DYSPHAGIA
Eg. “I know I will be eventually confined in the wheelchair
The muscle weakness – will eventually lead to RESPIRATORY DEPRESSION
s/s of generalized muscle weakness: FACIAL – diplopia Impaired Cerebellar Funx
LABDATA
CSF – Increase CHON EMG – “contract and relax” –
needle insertion Muscle biopsy
Ataxic Gait – “lasing” Impaired Sensation – NO HOT/COLD BATH
NSG DX
Ineffective Breathing Pattern
PI
AIRWAY (tracheostomy) SUPPORTIVE Refer to Geneticist
Impaired Sensory Funx – impotence LAB DATA #1 MRI – specific test for MS – it localizes the area of plaque formation or the area of dyemlination #2 CT SCAN NSG DX
same with GBS & MG
DRUGS
STEROIDS Anticonvulsants – dilantin Muscle relaxant – Baclofen Bladder Stimulants – Urecholine
(bethanicol) HX TEACHINGS
AVOID : HOT COLD SHOWER Refer to PT: ROM Exercises
SIDE NOTES: A Recessive : Cystic Fibro, Sickle Cell, Apalstic/Fanconis – either or both parents are (+) for trait NOT DSES A Dominant : Retinoblastoma, ALS – either father or mother (+) for disease or trait X Link Recessive : Hemophilia, Color Blindness, Duchennes Muscular, G6PD Dses – mother (+) trait NOT DSES and transmit to SON SPINAL CORD INJURY Destruction of S. Cord
AMYOTHROPIC LATERAL SCLEROSIS
related to TRAUMA
126 TYPES CERVICAL 8 – most serious – quadriphlegia THORACIC 12 LUMBAR 5 SACRAL 5 COCCYGEAL 1 PI SAFETY - immobilize, surgery LUMBOSACRAL AREA – if affected, therefore PARAPHLEGIA – bowel and bladder problem THORACIC - paraphlegia + bowel and bladder problem CERVICAL c1 – c4 - incomplete or partial quadriphlegia C5 – C8 - Complete quadriphlegia LAB DATA Myelogram CT Scan Xray
a.
Nsg Dx
Risk for Injury Impaired Physical Mobility
PI
SAFETY
Immobilize the spine – side lying w/ pillows bet
legs b.
Surgery
COMPLICATIONS OF SPINAL INJURY : AUTONOMIC DYSREFLXIA – due to full bladder and bowel s/s : #1 INITIAL : HPN #2 Diaphoresis
#3 slight fever what to keep at bedside: CATHETER - TO KEEP THE BLADDER EMPTY, BEC IF FULL IT WILL TRIGGER THE ANS
TIPS FOR NEURO A 10 yo is to undergo EEG, w/c comment made by a pt demonstrate that she understands the procedure – “I will wash my hair after the procedure”; A pt w/ tumor of the frontal lobe will most likely manifest – difficulty in concentrating; A pt w/ M. Sclerosis has urinary incontinence. To achieve voiding, w/c nsg care shld the nurse give – establishing regular voiding sked; While interviewing a pt. w/ Myasthenia gravis, w/c of the ff statements confirm the dx – “I have difficulty in swallowing”; A male pt w/ CVA is observed by the nurse to have consumed half of his meal, the PRIORITY Nsg Dx – Unilateral Neglect; When taking care of pt w/ C4 Spinal Injury, w/c equipment shld the nurse keep @ the b.side – Urinary Catheterization Set; The PRIORITY NSG DX for pt w/ Myasthenic Crisis – Ineffective Breathing Pattern
127 MP Maldevelopment of the Hips – that involves the acetabulum, head of femur or both S/S
MUSCULO CLUBFOOT DEFORMITY MP Congenital Foot twisted out of place Types
LAB DATA Talipes Varus – “inversion” Talipes Valgus – “eversion” Talipes Equinus – “tiptoe”
LAB DATA
PE Xray
Nsg Dx PI
Extra Gluteal Fold – at affected side; Ortoloni’s Sign – (+) Click Trendelenburg Sign or Pelvic Dropping – when child stand in one foot toward the affected side, then there is change in length Alli’s Sign or Galleazi’s Sign – shortening of the affected leg
click Ortolani’s – abduct leg sideward – (+) click Nsg Dx
Impaired Physical Mobility Promote Mobility
PExam Barlow’s Manuever – press leg downward – (+)
Impaired Physical Mobility
PI #1 Double or triple diaper – to keep legs in abducted position; #2 PAVLIK Harness - for 2-3 mos #3 Hip Spica Cast LAST RESORT
#1 MANUAL MANIPULATION #2 SEREAL CASTING – every 1-2 wks til position normalizes #3 DENNIS BROWN SPLINT – 2-3 months CAST : assess for s/s of neurological damage: Capillary refill – if more than 3 sec. - REPORT
NO ADDUCTION OF LEGS!
EDEMA FRACTURES Skin Color/ nailbed
CONGENITAL HIP DISLOCATION
MP Break in the continuity of the bone TYPES Open (compound) – bone tears the skin – therefore open: risk for infection CLOSE – skin intact
AVULSION – tear in the tendon
128
COMMINUTED - fragmented COMPRESSED – crushed IMPACTED – driven to each other DEPRESSED – pressed SPIRAL – goes around the bone GREENSTICK – incomplete
#1 Deformity #2 Pain #3 Edema #4 CREPITUS – sound created when two bone surface rob each other
S/S
NSG DX
Impaired Physical Mobility
PI
MOBILITY – immobilize the fx
a. Splinting; b. Casting – check for edema – elevate the affected areas; - check skin color – capillary refill time - check for presence of blood stained c.
OUSTANDING S/S
Uneven Hemline; Uneven waistline; Uneven shoulder (+) Rib Hump Prominent Iliac Crest
LAB DATA Bend Over test – instruct to touch the toes and note for rib hump Xray Nsg Dx
Impaired Physical Mobility - child Body Image Disturbance - adolesence
After cast, - CRUTCH WALKING
2 point gait – indicated if both lower extremities has partial wt bearing; 4 point gait – indicated for partial wt bearing; 3 point gait - indicated if 1 leg is allowed partial wt bearing and the other one is N; swing through - when both legs need to moved past the level of the crutches swing to – when both legs need to be moved AT THE LEVEL OF THE CRUTHES going upstairs – unaffected then crutch (goodleg – crutch – bad) going down – crutch then bad leg – then good leg
SCOLIOSIS Lateral Deviation of the Spine STRUCTURAL – non correctible FUNCTIONAL - correctible
MP RF
TX a. To decrease curvature – wear BOSTON or MILWAUKEE Brace – for 23 hrs/day except bathing b. SURGERY – HARRINGTON ROD - LUQUE HX Teaching Avoid :
Bending Jumping Rope Playing Tennis Trampoline
Allowed: Brisk Walking Swimming
129 Cheer Leading OSTEOPOROSIS/ HUNGRY BONE MP
Loss of Bone Density
RF
#1 smoking AGING IMMOBILITY MENOPAUSE – decrease Estrogen Secondary to Existing Condition – as secondary Hyperparathyroidism S/S
PAIN Dowager’s Hump Short Stature Progressive Decrease in Height
LAB DATA
Nsg Dx
Decrease in Calcium Bone Densinometry Bone Scan Xray SAFETY
ARTHRITIS RHEUMATOID OSTEOARTHRITIS Common
GOUTY
FEMALE MALE/FEMALE
Affected Part Upper Extremities Extremities wt bearing joint
MALE Lower
How? MP DIET : High Ca especially 4 those with – OSTEOPOROSIS - spinnach - seafoods - sardines
ACTIVITY : Partial Weight Bearing (NO SWIMMING) – jumping rope - bicycle reading - brisk walking
MEDS : Ca Supplement - alendronate Fosomax – SIT UPRIGHT AFTER
Chronic, systemic inflammation of connective tissues Synovial joints and joints of Upper extremities S/S
PAIN Inflammation Morning Stifness
Stages of Rheumatoid A.
STAGE 1 – no Disability STAGE 2 – with Interference To ADL
130 STAGE 3 - with major compromise of funx STAGE 4 - incapacitation
Diet : Low Purine/ Purine Restricted: AVOID : Organ Meats SEAFOODS
ULNAR DRIFT
SWAN NECK
DEFORMITY LAB DATA
Decrease HgB Increase ESR
Nsg Dx
PAIN Impaired Physical Mobility
PI a. Warm Bath; b. MEDS :
Relief of Pain ASA - Antiinflammatory STREROIDS c. exercise: ROM
Alcohol ALLOWED: Cheese (EXCEPT fermented and Aged) Increase ORAL Fluid Intake
OSTEOARTHRITIS A degenerative joint disease that involves the weight bearing joints – elbows & knees S/S
GOUTY ARTHRITIS
PAIN – NO inflammation Bouchard’s Nodes (distal) Heberdene’s Node (proximal)
MP Metabolic disorder of purine w/c leads to deposition or uric acid at joints site: THE GREAT BIG TOE
LAB DATA
S/S
Nsg Dx
PAIN Impaired Physical Mobility
PI
Weight Control
-
(+) PAIN – usually aggravated by pressure (+) Inflammation above s/s affects the LOWER EXTREMITIES
LAB DATA
Increase Uric Acid
NSG DX
PAIN Impaired Physical Mobility
PI
Relief of PAIN Meds : Allupurinol, Probenecid
xRAY
Health Teaching
Hot or Cold Compress ASA Trunk Assistive Device (cane)
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
131 Autoimmune multi system dses characterized by inflammation of connective tissues JOINT : stiffness; CARDIOVASCULAR : CNS : Irritability, Headache
(+) pain, (+) morning TIPS FOR MUSCULO (+) chest pain; (+) s/s of dec LOC,
OUTSTANDING S/S BUTTERFLY RASH (also present in pt in PROCAINAMIDE TOXICITY)
the priority nsg care for the pt w/ bucks extension traction shld be – ensure that the traction applied to the affected leg is always attached to the weight;
LAB DATA
Increase ESR
pt in russel’s traction is being taken cared of by the nurse, it would be necessary for the nurse to intervene if – the pt feet are pressed against the foot board;
Nsg Dx
PAIN Altered Tissue Perfusion Risk For Injury
a pt is using CRUTCHES for the first time, w/c action reflects a need for further instruction – the pt bears his/her wt with his/her axial;
TX available s/s
Symptomatic/ Supportive – meaning, treat
Drugs
Steroids
a pt on buck’s traction of the R femur ask the nurse how he can possibly move around. What can the nurse advise the pt – you can hold on to the trapeze bar while moving; w/c of the ff can possibly indicate the presence of abnormality in an adolescent – uneven hemline – scoliosis;
TRACTION PRINCIPLES
T – rapeze bar R – equires free hanging weights A – nalgesic C – iculation monitoring T – emperature monitoring I - nfection prevention O – utput and input monitoring N – utrition S – kin Assessment
when assessing an infant, w/c of the ff needs to be reported – extra gluteal folds; post spinal fusion –ROBAXIN –is given for w/c of the ff purpose - to decrease muscle spasm; a child has hip spica cast upon discharge, w/c statement of the father indicates further instruction – “ I will hold on to the bar bet his legs to help move him”
132 BURNS Traumatic injury to the skin brought about by : FIRE CHEMICALS PROLONGED EXPOSURE TO SUN ELECTRICAL CURRENT HOT H2O CLASSSIFICATION: According to Damage
PARTIAL THICKNESS – FIRST DEGREE 2ND DEGREE
EPIDERMIS DERMIS Pain Redness Eg sunburn FULL THICKNESS THIRD DEGREE
4TH DEGREE SUB Q
MUSCLES MUSCLES & BONES LEATHERY APPEARANCE CHARRED APPEARANCE NO Pain
Pain
Burn – triage : face and perineum (priority)
Redness Blister Formation pain
SUB Q FATS
FATS
INTEGUMENTARY SYSTEM
EPIDERMIS & PART OF
MODERATE PARTIAL TICKNESS 15-25%
MINOR MAJOR less than 15% 25%
No
133 FULL THICKNESS >10%
NONE
<10% LYME’S DISEASE Mountain Fever
Rocky
RULE OF 9 – CHECK NOTE day 9 page115 caused by BORRELIA BURGDORFERI (deer Dermacentor/ Variabilis – dog ticks
ticks) BURN TRIAGE Priority : Burns of
THINK:
FACE PERIMEUM UPPER & LOWER EXT Burn related to Child Abuse Chemical – Fire
R escue A larm C onfine the Fire E xtinguish the Fire
3-30 days or Dermacentor Andersori (wood) 2-3 wks
s/s :
Fever, Pain, Chills,
Rashes RASHES: Bull’s Eye Rash or Rounder Rings Generalized rashes At moist body parts
PRINCIPLES OF NSG CARE FOR BURN PTS:
B – reathing – Airway U – rine output monitoring R – esuscitation of Fluids N – utrition S – ilvadene Ointment
Complications Cardio, Musculoskeletal and CNS - which can lead to paralysis TX been to the woods?” PI
DIET DAT (High CHON, Ca, Vit C) Complication
FIRST 24HRS – SHOCK 72Hrs - INFECTION
Pt Preparation : Bed Craddle
Avoid wooded area – “have you Vaccination Use long sleeve Remove ticks w/ twizers – upward
straight motion Meds
Chloramphenicol Tetracycline
134 Causative Agent Herpez Virus Rubella Virus
DERMATITIS
INC PERIODUnknown 14 -21 days
DIAPER (contact) ATOPIC ECZEMA (adult) Peak : During infancy – 9-12 mos Cause : Hereditary Due to prolonged exposure to urine, soap & excreta Prone to asthmatic patients
Measle Virus 10 -20 days
s/s
FEVER and RASH
RASH Non Pruritic Begins w/ face & downwards Face & downwards Rose pink – begins w/ trunk Progressing outward
S/S : RASH RASH + scaling, Crusting
With KOPLICK’S Pruritus or itching
SPOTS +
same 3 C’s : Coryza Cough Conjuctivitis
Viscicles Management: Hydrate the skin w/ cold compress
MANAGEMENT: (to all types) Bed rest Antibiotics Antipyretic
Meds: Benadryl (antihistamine)
ROSEOLA RUBELLA
RUBEOLA
Exanthem GERMAN MEASLES
MEASLES
SYPHYLLIS HERPEZ C Agent
T Pallidum Zoster
GONORRHEA N Gonorrhea Simplex
135 I. Period
10-13 wks
Vericella Zoster Virus
2-7 days
Herpes Simplex Viruz TRICHOMONIASIS MONILIASIS/CANDIDIASIS
Abdominal
Oral Herpez
Genital H
Caused by TRICHOMONAS Vaginalis Albicans Both are STDs
2-12 days vesicle Charac of discharge : Greenish/ Yellowish WHITISH-CHEESELIKE discharge With FOUL ODOR
Steroids Around the mouth
Inner thigh
Inc Period
4 – 20 days
2
– 5 days Buttocks Genitals
Druf pf Choice Amphotericin
Flagyl
Acyclovir Cervical Ca – complication of Herpez Annual pap smear TIPS A nurse admits 8yo brought by her mother. Upon assessment, the nurse finds rounded rings of rash. This is indicative of – lyme’s dses; During the immediate 24hrs pot burn, w/c of the ff is the priority – administration of fluis;
136 A pt tells the nurse that he notice small blisters on his private parts. This is indicative of – HERPEZ A pt with CA of the cervix was admitted with the ff data: w/c one indicates a possible risk factor – previous tx for herpes; w/c of the ff indicates effective tx of gonorrhea – (-) purulent discharge; a pt is diagnosed w/ herpes zoster, w/c of the ff is the priority nsg dx – PAIN; w/c of the ff is indicative of CHLAMYDIASIS – burning on urination
RF Laryngeal or Oral CA
Smoking :
Lung, Bladder and
RACE
Jewish – Breast Blacks - Cervix and
:
Prostrate Whites – Testes PARITY breast having baby after 35 yo
:
Nulliparity –
Multiparity – cervix DIET
:
High Fat and Low
Fiber – CA of Colon Spicy – Ca of Prostrate Raw – Ca of Stomach LABDATA
Screening Exams Male:
a. Testicular Self Exam – mothly – begins age 16 yo- target are high school Female: a. Pap smear – at age of 18 (if sexually active) - anually b. Breast self exam – beginning age 20 – monthly c. Mamography – baseline : 35-40 yo : AFTER 40 yo – once every 2years After age 50 – annually CANCER Cause Unknown Theory of USE Overuse, Underuse, and Abuse
BOTH MALE AND FEMALE Digital Rectal Exam ANUALLY
40 and above –
137 Sigmoidoscopy age 50yo STOOL FOR OCCULT BLD Nsg Dx Knowledge deficit
ANUALLY after
TESTICULAR testes or lump (N – smooth unequal)
crytorchidism, spongy
Annually after age 50 yo Initial
:
If pt is TERMINALLY ILL
:
TIPS FOR CANCER
HOPELESSNESS If pt has some wishes or Unfulfilled needS : Powerlessness
w/c nsg dx is a priority for a pt undergoing chemotherapy – SOCIAL ISOLATION; when undergoing chemotheraphy, w/c solution is used for mouth care – HYDROGEN PEROXIDE;
Nsg Care Principles : C hemotherapy – target cells : those rapidly dividing cells; A sess Body Image N tuition/diet : high CHON, well balance C aution pt on s/s E xercise R est
w/c of the ff is an appropriate diet for pt undergoing chemo – bland diet; the most common sign of Breast Ca is in – upper outer quadrant;
pt w/ CA of esophagus will manifest – DYSPHAGIA
COMMON S/S LARYNX VOICE or Hoarseness LUNGS cough or smoker’s cough (productive) STOMACH BREAST discharge OVARIAN fullness or indigestion CERVICAL PROSTRATE phosphatase, nocturia COLON bowel habits Hodgkin’s Dses enlargement of lymph nodes
change in changing dyspepsia a lump or a complains feeling of “bleeding” elevated acid change in painless
TIPS FOR
PSYCHE
A pt w/ chronic depression is to undergo ECT, the purpose is to – relieve the symptoms of depression; A nurse shld assess the pt w/ ALZEIMER’S DSES for possible change in – orientation; A pt w/ bipolar episodes is ready for discharge when – she can comply with units activities;
138 The nurse would suspect that the child is a victim of abuse if he – keeps quiet while an IV is inserted; w/c of the ff situations reflects an increase in selfesteem of an abuse child - when he ask the nurse for a plastic cup to drink; the initial care plan for a pt with Anorexia Nervosa would require the pt to – remain in public place 1 hour after meals;
the nurse notes mirror image in the fetal monitor – this could be related to FETAL HEAD COMPRESSION; which of the ff is related to trauma – ABRUPTIO PLACENTA; A nurse is caring for a woman in first stage of labor, she is timing the duration of contraction – she is correct when she times it from the beginning of one contraction to the end of same contraction
where shld the nurse put the pt on early alcoholic withdrawal – well-lighted room near nurses station TIPS PEDIA w/c of the ff is expected by 6mos of age – sits w/ minimal support; the most appropriate toy for 18 mos old child – carriage w/ a doll; the appropriate room mate for an 8yo girl w/ leukemia is – 6 yo with hemophilia; in a 3yo child – w/c of the ff shld the nurse assess during admission – special words used for objects and routines;
TIPS FOR OB-GYNE A Mother Is Crying Besides her baby, she said “I feel so sorry I couldn’t hold her” – let her stroke the baby; 6wks pregnant woman ask the nurse about the signs of pregnancy – w/c one is expected at this time – frequent urination;
w/c of the ff is appropriate way of administering preop meds to 4 yo child – ask the child where she would like the injecvtion to be given
139
140
141
142
143
144
Paralysis of Lower
