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 ¼ ve a Fresh Start KNOW what YOU WANT and HOW TO GET IT OVERVIEW OF ESSENTIAL CONC EPT TRY OUT Focus assessment 7 habits of SUCCESSFUL EXAMINEE MOSBY ± growth and development LIPPINCOTT ± care of the Elderly and Communicable Dis ease DIGOXIN ± monitor the creatinine¼ ª the TV DOESN'T look good to meº (DIGOXIN TOXICITY ± nausea/vomiting, abdl cramps) Olive = butter CK ± normalize 1 ± 3 days after MI LDH - 10 ± 14 days ATRIAL FLUTTER ± SAW TOOTH PROCESS OF ELIMINATION consider MASLOW's of NEEDS consider the COMPLICATION whether ACUTE CHRONIC ABCs SAFETY FIRST NSG P ROCESS ± ALWAYS prioritize MMR VACCINE ± only vaccine for HIV pt. Pt on HEPARIN ± APTT (N 30-40sec), therefore if INCREASE ± bleeding POISON - nursing action in order : #1 CALL poison control c enter # 2 MINIMIZE EXPOSURE of pt to poison ± pull him/her away from the poison # 3 IDENTIFY the poison GENTAMYCIN ± s/e tinnitus, vertigo, ototoxicity, oliguria ± for ELDERLY : N level NOT more than 1.0meq/L ADULT : N .5 ± 1.2 meq/L LITHIUM CARBONATE HEPA B diet : low fat, increase CHON
DOWN SYNDROME ± large tongue ± feeding problem ± poor sucking (infants) SAFETY PRINCIP LE 1. when can a child USE ADULT SEAT BELT? - if the infant is 40 lbs and 40 inc hes in height seat belt location in car: BACK CENTER SEAT 2. TODDLER ± falls 3. SU PRATENTORIAL craniotomy ± semi fowler's position INFRATENTORIAL ± flat in bed 4. SCATT ER RUGS ± osteoporosis pts. 5. TRIAGE ; burns, open fx ± ªSHOCKº Things NOT TO BE DELEGA TED by RN: Assessment, Teachings, Evaluation Pt 50y/o and - mammogram ± once a yea r. Pt with PKU ± LOW PHENYLALAMINE DIET (NOT phenyl FREE). ± therefore LOW CHON Pt with Rocky Mountain Fever ± exposure to dog ticks Lyme's Dses ± deer ticks PSYCHE PATIENTS 1. remember to stick to unit rules/policy ± be consistent to pt. 2. encourage ver balization ± ªtel me how¼..º 3. sound knowledge of cultural diversity - seek help of int erpreter 4. acknowledge pt feelings ± ªit seems¼.º ªthis must be difficult¼..º 5. emphatize w th your patients's feelings ª I understand how you feel¼..º CATARACT ± CAUSES ± aging and tr auma MRSA (methicillin resistant staphyliccocus aureus) - USE GLOVES AND GOWN WH EN W/ PT DAY 2 ( 01 February 05)
TUBES 1. GROSHONG CATHETER HICKMAN BROVIAC - 2 lumen - 3 lumen - 1 lumen ALL requires Central Venous Access - sites: cephalic, brachial, basilica and sup erior vena cava PURPOSE: For TPN Administration of Chemo Agents, Blood Products, Antibiotics COMPLICATION:Thrombosis and Bleeding 2. CHEST TUBES ± Water Sealed Drainage Types: COMPLICATION:Thrombosis Anterior ± w/c drains AIR Posterior - w/c drains FLUIDS Water Sealed Drainage : 1 bottle, 2 bottle and Three bottle system 1 BOTTLE : 2 BOTTLE : 3 bottle : 3 ± 5cm of only (length of tube to be emerge) First bottle ± drainage bottle (no tube eme rge), 2nd bottle - long rod 3-5cm FREQUENTLY USED 1st bottle ± drainage 2nd bottle ± water sealed 3rd bottle ± suction bottle control COMPLICATIONS: Nsg ALERT: 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 bubb ling occurs at the 2nd bottle ± indicates LEAKAGE ± action, check sealed at air tigh t container and the pt and bottle connection. bubbling, breakage, blockage
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 b ottle LOWER than the patient. ABSENCE of OSCILLATION at the 2nd Bottle ± indicates blockage TOWARDS THE BOTTLE - When MILKING the tubings. EMERGENCY EQUIPMETS AT BEDSIDE: x tra bottle,clamp, gauze 3. TRACHEOSTOMY TUBE - to maintain patent airway for pt w/ neurological problems and musculoskeletal disorders.
nursing care: 1. Suctioning ± 10-15seconds - if (+) bradycardia, STOP - if acciden tally 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. Ribbon or ties @ side of the neck only to avoid pressure. 5. Before and After suctioning ± h yperoxygenate 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 Pro blem: 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. - r emove gradually 6. NASO GASTRIC TUBE ± stomach and intestine (duodenum) Types: Levine Tube ± for sto mach - 1 lumen, for lavage (cleaning) and gavage (feeding) Salem Sump ± for stomac h - 2 lumen (I for suctioning, I for lavage/gavage) - if pt (infant) is having e nteric coated meds, request for change in form of meds Miller Abbot ± for intestin al (w/ mercury b4 injection) - 2 lumen (insert then inject the mercury) Cantor ± f or 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 me ans to verify correct placement: ALWAYS consider Two checking criteria: ASPIRATI ON and Gurgling Sounds
Report the following: If (-) or decrease drainage, (+) nausea and vomiting (+) abdml rigidity Characte ristic of Gastric Residual: more than 50 mo and coffee ground. Before feeding ch eck for placement. 7. GASTROSTOMY TUBE (GT) PEG · both for NUTRITIONAL PURPOSES GT ± incision (abdomen to stomach) - for pt (+) lesion at esophagus - nsg care : report s/s of infectio n, abdl cramps, n/v - provide adequate skin care PEG ± incision at skin - long ter m therapy 8. T TUBE - to drain excess bile until hearing occurs - place drainage bag at th e level of t-tube (obstruction of t-tube ± there will be excess drainage) 500 ml ± N drainage in 24hrs, if report ASAP. 9. HEMOVAC JACKSON-PRATTS (JP) BOTH used as close wound drainage suction system BOTH system function on the system of (-) pressure. 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 Characteristic of drainage ± 2-3 day s after surgery (bloody to pinkish) ± NO NEED TO REPORT THIS ± it is expected
11. SUPRAPUBIC CATHETER ± for genito urinary problem - inserted directly at the bl adder wall - check if properly anchored 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. SENGSTAKEN BLAKEMORE TUBE - 3 lumen ( for esophageal balloo n, 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 ± 4 lumen MINESOTTA TUBE
SCISSORS ± important EQUIPMENT AT BEDSIDE FOR ALL TUBES. HEMOSTAT ment that shld be @ bedside for water sealed drainage. Persistent ter drainage bottle ± for bottle #2 ± check if tubing is properly OVED ± if patient exhibits return of bowel sounds. BULB SYRINGE ± ares of pt with NGT (child) To facilitate removal of air at lungs er sealed chamber in 3 way bottle system.
± important instru bubbling at wa sealed. NGT IS REM use to clean the n ± purpose of wat
THERAPEUTIC DIET GENERAL CONSIDERATION Know the DIAGNOSIS of the patient Identify & incorporate t he pt. dietary preferences Instruct pt on what to avoid For pregnant pt, note di etary changes: a. addtl calories (300 cal/day) average of 2400 - 2700 b. addtl o f 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 (-) extr usion reflex. - cereals, fruits, vegetables,meat and table foods - egg yolk (6mo s), egg white (1yr)
TRANSCULTURAL CONSIDERATION CHINESE ± like cold desserts after surgery for optimum health JEWS ± ªkosher dietº (no meat and diary products at the same time) EUROPEANS ± m ain meal is served at mid day followed by espresso MUSLIM ± ªhalal dietº ± no pork SDA ± trictly vegs diet (vit B6 and B12 deficiency) MORMONS ± words of wisdom (no caffei ne, 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 KNO W the serving: CHO - 6-11 servings CHON - 2-3 FRUITS & Vegs - 3-4 FATS - sparing ly MOST COMMON DIET CLEAR LIQUID DIET (light can pass thru it, meaning TRANSPARENT) - 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 dis order (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)
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 SOFT DIET for inflammatory conditions: esophagitis, pe ptic ulcer gastritis pureed foods/ blenderized foods soup
PURINE RESTRICTED DIET for gouty arthritis increase fluid intake AVOID: preserve d foods, sea foods, alcohol, organ meat (liver, gizzard)
NA RESTRICTED DIET for cardiovascular dses, renal, fld & e imbalance ALLOWED: fr esh vegs AVOID : processed foods, milk products and salty foods
BLAND DIET for peptic ulcer, inflammatory GI conditions AVOID: chemically and mechanically irritating foods such as fried foods, fresh and raw fruits & vegs (EXCEPT: avoca do, banana & pinya) and spicy foods with preservatives
HIGH PROTEIN, HIGH CARBO DIET for burns (about 5000 cal/day) grain products and poultry ± to aid the healing tissues
ACID ASH DIET 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
ALKALINE ASH DIET to increase ph of the urine indicated for acid stone ( uric ac id stone, cystine stone) ex. Milk
GLUTEN-FREE DIET for celiac dses ALLOWED : rice, corn, cereals, soy beans AVOID (LIFETIME): barley, rye, oats, wheat
PHENYLALANINE DIET for PKU, until age 10 and adolescence only AVOID : CHON rich foods (meat products ± luncheon meat)
FULL LIQUID DIET opaque transitional diet from liquid ex : cream soup, ice cream , milk, leche flan, pumpkin cake ªABGsº ATERIAL BLOOD GASES Ph ± 7.35 ± 7.45 PCO2 - 35 ± 35 HCO3 - 22 ± 26 meq/L Ph Compensatory Mechanism no change increase or decrease increase or decrease Uncompensated abnormal Partially compensated abnormal Fully Compensated normal D iarrhea ± metabolic acidosis Vomiting ± metabolic alkalosis PRIORITIZING of case: Med.-Surg ± ªabcº Psyche - safety first Fire - race Triage - pt evaluation system (prioritizing) APGAR SCORING
0 Appearance Pulse Grimace Activity Respiratory pallor (-) (-) flaccid (-) 1 2 all pink flexion & extension acrocyanosis <100 >100 grimace vigorous some flexion irregular lusty cry T.R.I.A.G.E -prioritizing LEVEL 1 ªemergencyº severe shock, cardiac arrest, cervical spine injury, airway compromise, altered level of consciousness, multiple syste m trauma, eclampsia LEVEL 2 ªurgent (stable)º LEVEL 3 chronic/ minor illness (can be delegated) ± dental p roblems, routine medications and chronic low back pain can be delegated (fever, minor burns, lacerations, dizziness) TIPS ON PRIORITIZING 1. PT @ ER ± sleeping pills overdose; 2. pt bp 80/30 & mother died of CVA 1st prio rity : assess pt for addtl risk factor; 3. pt ask what procedure: Rn Action : no tify the doctor 4. MI attack ± 1st action : report ASAP (esp. presence of vent. Fi brillation) 5. pt on NGT ± check patency of tube DELEGATION do not delegate Assessment, Teaching and Evaluation do not delegate meds prepara tion, administration, documentation CONCEPT OF DELEGATION consider the competence of personnel 5 R's in delegating (RIGHT task, person, circ umstances, direction/communication supervision) RN may delegate ± feeding client, routine vital sign (pt w/ no complications) and hygiene care
MI ATTACK ± enzymes to increase IN ORDER - #1 #2 #3 #4 myoglobin troponin CK LDH RISK FOR INJURY ± meniere's dses INEFFECTIVE BREATHING PATTERN ± myasthenia gravis ALT ERED TISSUE PERFUSION ± pt w/ complete heart block INEFFECTIVE AIRWAY CLEARANCE ± pt w/ kussmaul's breathing D DAY 3 ( 02 February 05) POSITIONING FOR SPECIFIC SURGICAL CONDITION Positioning a. b. c. ± independent nsg function know the purpose of the position t o prevent or promote soothing; what to prevent or promote; know your anatomy & p hysiology ± R side lying ± to prevent bleeding Post Liver Biopsy
(during the procedure ± L side lying). Hiatal Hernia ± upright to prevent reflux.
AMPUTATION complication: hemorrhage (keep tourniquet @ bedside) 1st 24hr ± goal: t o decrease edema ± elevate the stump at foot part w/ the use of pillow AFTER 24hr ± goal : to prevent contracture deformity (keep leg extended)
APPENDICITIS Unruptured : any position of comfort Ruptured : semi to high fowler's position to prevent the upward spread of infectio n complication: peritonitis Ruptured appendicitis indication: pain decreases or go away. (pt say, ªI want to go home pain is goneº) BURNS Position is FLAT or Modifi ed Trendelenburg ± to prevent shock. SHOCK occurs w/in 24-48hrs (immediate post bu rn phase). Complication: infection
CAST, EXTREMITY Elevate the Extremity ± to prevent edema (use rubber pillow) Nsg care: a. b. c. d. e. capillary refill ± N 1-3 seconds only (complication: alte red circulation) note for s/s of infection (when there is musty odor inside the cast) pruritus (inject air using bulb syringe) blood stained ± mark and note (if i ncreasing in diameter - report ASAP) tingling sensation ± indicate nerve damage
CRANIOTOMY Types: a. Supratentorial C ± semi fowler's orlow fowler's position ± to prevent accumulation of fluid at surgical site; b. Infratentorial C - flat or supine. Purpose: same
FLAIL CHEST (+) Traumatic Injury ± paradoxical chest movement ± areas of chest GOES IN inspiration and OUT on Expiration position: towards the affected side to stabilize the chest.
GASTRIC RESECTION to prevent dumping syndrome ± usually for 10 mos only NOT LIFETI ME disorder (post gastrectomy) position : LIE FLAT for 1-2hrs post meal
HIATAL HERNIA there is damage to esophageal mucosa what to prevent: gastric refl ux therefore FEEP PT IN UPRIGHT POSITION.
HIP PROSTHESIS Position: to prevent subloxation (KEEP LEG ABDUCTED) with the use of wedge pillow or triangular pillow from perinium to the knees. dumping syndrome : ªflatº
LAMINECTOMY ªlog-roll the patientº (3 nurses) ± KEEP SPINE IN STRAIGHT ALIGNMENT
AVOID: hyperflexion, hyperextension and prone ± it causes hyperextension of the sp ine.
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 b leeding.
LOBECTOMY 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 eleva te higher that the level of the heart. AVOID: venipuncture, specimen taking, blo od pressure ± ON THE AFFECTED ARM coz there is no more lymph node w/c predispose p t 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 PNEU MONECTOMY either L or R lung. Position pt on the AFFECTED SIDE to promote lung e xpansion.
RADIUM IMPLANT OF THE CERVIX keep pt on complete bed rest to prevent dislodge. A VOIDE SEX (may burn penis bec of the implant inside)
RESPIRATORY DISTRESS Adult : Orthopneic position ± over bed table then lean forwar d Pedia : TRIPOD ± lean forward and stick out tongue to maximize the Airflow RETIN AL 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: sudde n head movement.
VEIN STRIPPING keep extremities extended then elevate the legs at level of the h eart 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; when draining the L lower lo be 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 a pt is about to go o n thoracenthesis - how shld the nurse position the pt? ± sitting w/ a arms resting on the overbed table; to maintain the integrity of pt w/ hip prosthesis ± abducti on splints immediately after supratentorial craniotomy- fowler's position best pos ition for pt in shock ± supine w/ lower extremities elevated THERAPEUTIC COMMUNICATION 1. DON'T ASK WHY ± this put pt on the defensive 2. AVOID PASSING BACK ± ªI will refer yo u to¼.º 3. DON'T GIVE FAKE REASSURANCE ± ªeverything will be alright¼.º ªyou're in the hands e bestº 4. AVOID NURSE CENTERED RESPONSE ± ªI felt same too¼º ªI had the same feeling¼.º In G P DISCUSSION ± nurse is just a facilitator ± let the group decide, he/she channel ar e concern back to the group. THERAPEUTIC PHRASES ± it seems¼ you seem¼. - open ended q uestion - close ended ± for manic pt and pt in crisis - direct question- for suici dal pt
ISOLATION PRECAUTION Purpose : to isolate infection transmission TYPE PRIVATE ROOM HAND WASHING GOWN GLOVE MASK STRICT (airborne dses, direct contact-Diptheria) RESPIRATORY (AIRBORNE: BEYOND 3FT DROPLET : W/IN 3FT) OPTIONAL OPTIONAL TB CONTACT OPTIONAL (negative airflow room) OPTIONAL (direct contact ± NOT AIRBORNE DSES) eX SCABIES ENTERIC (fecal contamination) X OPTIONAL OPTIONAL DISCHARGE X (drainage: pus ex burn pt) UNIVERSAL X OPTIONAL OPTIONAL (AIDS, HEPA b ± TRANSMITTED BY BLD AND DODY FLUIDS) TIPS: When implementing universal precaution, w/c nsg action require intervention: rec apping the needle ± this might prick your hand; When discarding the contents of th e bed pan use by a pt under enteric precaution ± GLOVE IS NECESSARY; A nurse is gi ving health teaching to the parents of child with scabies: family member must be treated; Preventing pediculosis in school age children: avoiding contact w/ hai r 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 visi tors is wearing mask ± response: it will help in the prevention of infection;
Essential when a pt w/ meningitis is kept in isolation: isolation precaution rem ains until 24hrs after initiating antibiotic therapy DIAGNOSTIC PROCEDURES side notes: pt for IVP pt for KUB schilling test USG : : : : assess for allergy (cleansing enema b4 the procedure) no dye (don't assess for allergy) 24hr urine sp ecimen no consent required GENERAL CONSIDERATION · EXPLAIN the procedure to the pt (initial nsg action) if not ready inform the doc tor; pt has the right to refuse procedure; doctor the one who asked for consent Check pt for CONSENT ± if INVASIVE ± WITH CONSENT NON INVASIVE ± NO CONSENT needed CON TRAST MEDIUM ± check for allergy For procedure requiring anesthesia ± KEEP PT NPO B4 PROCEDURE 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 TRANSCULTURAL CONSIDERATION HISPANIC PATIENT ± women prefer same gender health care provider Obtain help of in terpreter when explaining procedures ± (except or don't ask family members) For musl im patient - they prefer same sex health care provider however, if procedures re quire life threatening ± they prefer to have male doctor. - they only want good ne ws information of their condition DELEGATION and DOCUMENTATION Delegation ± assessment, monitoring and evaluation of treatment (cannot be delegat ed) BUT standard and changing procedures can be delegated ex. ± 24hr urine specime n and urine catheter
collection. Documentation ± type of treatment and any untoward reactions. KEYPOINTS FOR NURSES Prepare the patient; Monitor for adverse reaction; Report c omplication 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 mov ements ± 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 monitor the baseline FHR then induce fetal movements by (HOW) : a. ring a bell b. feed the p atient then check FHR, NST is (+) if FHR increase at least 15 beats/min than the baseli ne. (ex. 140 FHB baseline, then after challenge it increase to 155) POSITIVE res ult 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 T EST (oxytocin challenge test) HOW: Thru breast stimulation ± it triggers the relea se of oxytocin from pituitary gland¼ If (-) patient is given Oxytocin ± onset is 2030 minutes. Then check FHR and note the presence of DECELERATION (slowing of FHR ) types of deceleration a. early deceleration ± indicates head compression (MIRROR I MAGE)
correlates FHR with uterine contractions pt on NPO get baseline FHR then induce uterine contraction 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 ca n occur anytime.
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.
BIOPHYSICAL PROFILE ± to determine fetal well being w/ the use of 5 CRITERIA 2 poi nts 2 points 2 points 2 points 2 points 10 points fetal breathing movement heart tone reaction to NST amniotic fld volume score be low 6, indicates fetal jeopardy
ULTRASOUND - provide data on placenta (age and location) gender of baby structur al abnormalities position of baby - for pregnant: site is lower abdominal USG types: a. Upper USG ± NPO b. 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 CHORIONIC VILLI SAMPLING ± CVS AMNIOCENTESIS ± AMNIO PERCUTANEOUS UMBILICAL CORD BLO OD SAMPLING ± PUBS CVS Purpose: to detect chromosomal Aberration (eg. Down syndrome, Trisomy 21) Done i n 1st trimester (can be done as early as 5th wk but can be done on 8-10th wk) AMNIO Purpose : same w/ CVS PUBS Purpose: to check chromosomal aberrations, & presence of RH Incompatibility Extr act blood at umbilical cord then it is tested if it really comes from the umbili cal cord (can be done on either 2nd or 3rd tri. can be done on the 2nd wk (14-16 wk) - but not recommended bec. of danger aborti on (assess pt age of gestation) or can be done on the 3rd wk (34-36 wk) purpose: to detect fetal maturity (FLM) thru monitoring of L/S Ratio N 2:1 (if mother is (+) DM LS ratio is 3:1) This procedure also check level of alpha-feto Protein ± i f INCREASE ± spina befida; If DECRTEASE ± down syndrome Get sample at chorion (by 10-12wks ± The placenta matures, get some sample) (+) Consent ± invasive Bladder : Empty (+) Consent consider the Pt Age of Gestation (if age of gestation : (+) Consent
is higher than 20wks and above : empty bladder, if AOG is 20wks and below : full bladder COMPLICATIONS of CVS, AMNIO & PUBS: a. b. c. d. infection bleeding abortion feta l death TIPS · EARLY DECELERATION ± expected in the fetal monitor when there is fetal head compre ssion; · AMNIOCENTESIS ± was done @ 35 wks gestation ± purpose: to determine fetal lung matur ity; · A mother asked the nurse what will amniocentesis provide during pregnancy: it wi ll 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 n eeds further teaching ± pt voids b4 the procedure; · after amniocentesis w/c of the following manifestation if observed by the nurse on the patient that needs to be reported : bleeding; · heart rate; · pt ask the nurse ± what deceleration means ± it refers to slowing of baby's before Amn iocentesis, what to check ± USG DEVICE DIAGNOSTIC TESTS (to evaluate pediatric patients) CARDIOPNEUMOGRAM ± use to diagnose apnea of infancy ± assess HR, RR, nasal airflow a nd O2 saturation ± N 95-98% below 85 ± report ASAP GLUTEN CHALLENGE - detect presenc e 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: abdl cramps, steatorrhea, abdl rigidity, abdl distention (if + for CD, gluten free diet will be for life time)
ORTOLANI'S TEST (OT) purpose: test developmental dysplacia of the hip or congenital hip dislocation ( +) if w/ click sound (lateral) BARLOW'S MANUEVER (BM) purpose : same (+) barlow's click ± press downward and w/ click sound POLYSOMNOGRAPHY or ªsleep testº EEG is connected to pt when he sleeps Check the brai n waves, check for apnea of infancy 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 p resence of rib hump test for pre-teen : ªbend over testº ± bend and touch the toe; (+) scoliosis ± if presen ce of rib hump, therefore x-ray then scoliometer. SICKLEDEX TEST Purpose: test for sickle cell anemia HGB ELECTROPOISIS Purpose: test for sickle cell anemia Specimen : Blood : (blood + solution, if (+) TURBID Specimen : Blood : bld + ele ctropoiesis, if sickling of RBC Therefore TRAIT CARRIER (S or C shape RBC), ther efore + for SC Dses Test for TRAIT Test for Disease GUTHRIE CAPILLARY BLOOD TEST (GCBT) - to detect PKU (in PKU there is absence of PHENYLALAMINE HYDROXYLASE- PH) Phenylalamine hydroxylase ± is an enzyme that conve rts 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 usua lly negative, so give CHON food first for 3wks then retest. Before test, give ch on rich food for 1-4 days before test. (adult) N PH level - >2mg/dl (if 4mg/dl ± i ndicative of PKU, 8mg/dl ± confirms PKU)
SWEAT CHLORIDE TEST Types: a. sweat chloride test ± N 10-35 meq/L (above 40 +) b. serum chloride test ± N 90-110 meq/L (above 140 meq/L ± (+) to detect ibrosis (in CF, the skin becomes impermeable to Na. meaning cannot reabsorb nd it accumulates outside of the skin); Mother complain that her baby taste y; PILOCARPINE ± used in the test to induce sweating;
meq/L± ( Cystic F Na a salt
TIPS pt w/ PKU would more likely to have (+) result in gluten capillary bld test if t here is ± adequate CHON in the diet; mother complains that her baby taste salty ± wh ich test is to be performed : sweat chloride test; 9 yo pt has (+) result for sw eat test ± this indicates possible dx of Cystic Fibrosis; pilocarpine ± drug used fo r pt undergoing seat chloride test; hgb electropoisis ± test for sickle cell dses
DAY 4 (3 Feb 2005) DIAGNOSTIC PROCEDURES I. CARDIOVASCULAR A. ELECTROCARDIOGRAPHY ± records the electrical activity of the HEART P wave ± atria l depolarization QRS complex ± ventricular depolarization ST - repolarization Rhyt hm ± appearance of wave and distance Rate - N 60-100 bpm ± check on # of QRS then di vide it by 300 (k) ABNORMALITIES
a. al ± t
atrial fibrillation ± p waves ªhalos magkadikit. (no discernable p waves) b. atri flutter ± ªsaw toothº flutter waves c. ventricular ± check on QRS (N - .8-.12) ANGINA st segment elevation, t wave inversion MI - st segment elevation or depression, wave inversion
B. CARDIAC CATHETERIZATION it determine the structural abnormalities in the hear t either L or R sided catheterization site: antecubital, femoral, brachial common complications: embolism, bleeding, arrythimia ªEBAº nsg mgt : monitor distal pulses (if brachial site: check @ radial if femoral site : check @ dorsalis pedi s) if weak or no pulse ± REPORT if (+) bleeding ± report (ªsandbag 10-20 lbsº ± shld be a bedside) C. STRESS TEST determines the ability of the heart to withstand stress equipment : threadmill & ECG nsg alert : check pulse and BP keep NPO an hr b4 the test NO Jewelries D. CORONARY ARTERIOGRAPHY visualization of the bld vessels w/ contrast medium ns g alert: (+)consent check allergy to contrast medium increase oral fluid intake after to excrete dye epinephrine shld be ready for any untoward reaction E. SWAN-GANZ CATHETERIZATION 4 lumen for the ff CVP, Pulmonary Capillary Wedge P ressure (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) Addison's Dses: hyponatremia (dec Na), hyperkalemia (inc K) ± ªFLD IMBALANCEº Cushing Sy ndrome: hypernatremia, hypokalemia ± ªFLD VOL. EXCESSº
POTASSIUM (3.5 ± 5 meq/L) Hyperkalemia : Addison's dses Hypokalemia : Cushing Syndrome Inc or dec in K PT RI SK of INJURY Pt w/ digitalis & diuretics ± monitor for arrhythmia
CALCIUM (4.5 ± 5 meq/L or 9-10mg/dl) Hyperthyroidism ± inc CA Renal Calculi Formation ± inc CA @ bld
GLUCOSE (80-120) Higher than 140 ± hyperglycemia (acidosis ± may lead to ineffective breathing pattern and airway is the main problem) below 50 ± hypoglycemia (pt pro ne to injury & altered thought process)
Creatinine (.5-1.5) most sensitive index of kidney funx (increase BUN but N creatinine ± do not report to AP) increase creatinine ± kidney failure or renal disorder
BUN (10-20 mg/dl) inc. if (+) kidney disorder
LDH (40 ± 90 u/L) LDH1 ± 27-37% (for heart ± check for MI) LDH2 ± 17-27% (for heart ± check for MI) LDH3 ± 8 -15% (for respiratory system) LDH4 ± 3-8% (for liver & kidney) LDH5 ± 0-5% (for live r & kidney) LDH inc for MI for 3-4 days then it returns to N after 10-14 days
CPK or CK Male ± 12-70 u/L Female - 10-55 u/L Increase CPK 3-6hrs post MI then it normalize 3-4 dyas
AST (SGOT) - N 8-20 u/L - for liver (inc. for liver dses) SGPT (ALT) N 8-20 u/L more on HEART (inc for cardiac dses) G. HEMATOLOGIC STUDIES RBC (4.5 ± 5.5 million) - inc RBC ± polycythemia ± risk for inj ury ± 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 P LATELET (150,000-450,000) - spontaneous bleeding occurs when platelet dec (pt al so prone to injury) PT (11-12 sec) PTT (60-70 sec) APTT (30-40 sec) coumadin ± check pt monitor pt 4 bleeding heparin ± PTT monitor pt 4 bleeding HGB ± male : 14-18 mg/dl Female : 12-16 mg/dl Dec hgb ± anemia (nsg dx: activity int olerance) HCT - 35-45% - determine the adequacy of hydration and the ration of p lasma to the cellular component blood inc hct dec hct : hemoconcentration (nsg d x: fld deficit ± dehydrated pt) : hemodilution fld excess 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 finge r or earlobe (do not expose e light) II. RESPIRATORY BRONCHOSCOPY ± ± ± ± ± ± visualization of b. tree or airway passages; to gather specimen biopsy; NPO b4 & after Gag reflex return after 1-2hrs; Pt may expect a sore fee ling (PINK STINGED SPUTUM) Report (+) stridor CHEST X-RAY to determine abnormalities of lungs and thoracic cavity; no preparation; ABSOLUT E CONTRAINDICATED TO PREGNANCY Check pt for radiation indicator Determine effect iveness of tx and whether pt is active or non-active SPUTUM STUDIES to determine the gross characteristic of the sputum (refers to the amount, color, abnormal p articles, consistency and characteristic) TYPE OF SPUTUM PNEUMONIA TB - Viral ± thin & watery Bacteria - rusty - blood strea ked BRONCHITIS - gelatinous CHF/ PULMONARY EDEMA - pink stinged Sputum specimen ± sterile container
THORACENTESIS - aspiration of fld at thoracic cavity (for diagnostic & therapeut ic purpose) DURING ± sitting AFTER - affected or unaffected side position: 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 pneumotho rax PULMONARY FUNCTION TEST - thru the use of incentive spirometer - vital capac ity (4-5 L of air) ± refers 2 N amt of air that goes in
& out of lung after maximum inspiration. PROCEDURE: EXHALE then INSERT mouth piece, BREATH iN, HOLD then EXHALE
LUNG SCAN - to identify the presence of blockage in the pulmonary bld vessels; with contrast medium; - (+) consent; - assess for rxn to allergy 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 s ex, previously (+) pt; 10mm - (+) for immigrants, children below 3yo and for pt w/ medical condition ± DM & Alcoholism 15mm - (+) for general population LUNG BIOP SY - aspiration of tissues at lungs for dx of tumors, malignancy - assess for bl eeding, breath sounds & report for s/s of dyspnea
III. NERVOUS EEG shampoo hair B4 (to remove chemicals) and AFTER to remove electrode gel (sha mpoo or acetone) measures electrical activity of the brain (gray matter) non inv asive, (-) consent detect the ff: brain tumors, space occupying lessions alcohol brain waves and seizures nursing alert: dietary modification: WITHOLD CAFFEINE ± coffee and tea; WITHOLD 48hrs b4 the proc edure : 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 abnorm ality of tissue density; (detect cancer and tumor) also to detect O2 saturation @ tissue;
physiology of psychosis; and to evaluate tx give more detailed impression (ex. M easurement of blocked artery) like CA Tx NSG ALERT: (w/ or w/out dye) CONTRAINDICATION a. pregnancy; obese pt (more than 300 lbs); claustrophobia (give anti-anxiety b4) pt w/ unstable v/s (arrhythmic & HPN); pt w/ allergy to dye CONTRAINDICATION (same w/ ct scan BUT w/ addtl) NO METAL OBJECTS - jewelries, in sulin pump, pacemaker, hip replacement b. c. d. e. ªclicking soundº will be heard & lie still during the procedure lie still lie still during the procedure and ªthumping soundº will be heard -
CEREBRAL ANGIOGRAM involves visualization of bld vessels @ vein w/ the use of co ntrast medium. CONTRAINDICATED IN: pt w/ allergy; pregnant pt.; bleeding Nursing Alert: a. b. c. d. e. keep pt NPO; assess pt for allergy; monitor for si gns of bldg; inc oral fld intake to excrete dye; keep epinephrine and or benadry l at bedside for emergency -
LUMBAR PUNCTURE aspiration of CSF for assessment to check for infection or hemorrhage position: DURING : fetal or C-position AFTER : FLAT to prevent spinal headache Needle is inserted between L3 and L4 or L4 and L5 Increase fluid intake after.
CSF ANALYSIS Assess for the characteristic of CSF. N amount: 100-200 ml Characte ristic : Clear w/ glucose, Na and H2O
If REDDISH ± hemorrhage If Yellowish ± infection Ear licking w/ fluid ± test if (+) gl ucose bec. CSF has glucose. -
MYELOGRAM test for presence of slip disc or herniated nucleus porposus (HNP). ALERT: Know the type of dye use: a. water based ± called AMIPAQUE b. oil base ± called PANT OPAQUE type of dye will determine the position of pt AFTER the procedure. If wat er 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) IV. EENT · 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 movem ent of the eye. SEVERE NYSTAGMUS ± NORMAL MODERATE NYS - Minierre's Dses NO NYSTAGMUS - Acoustic Neu roma · GONIOSCOPY to differentiate OPEN and close angle galucoma;
non-invasive, painless RINNE'S TEST WEBER 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 Prob lem would be SENSORINEURAL LOSS; place at mastoid bone or in teeth then¼. if pt he ar better in POOR EAR, - refers to if AIR CONDUCTION is LONGER, therefore CONDUC TIVE HEARING LOSS SENSORINEURAL HEARING LOSS; If BONE CONDUCTION IS LONGER, ther efore CONDUCTIVE HEARING LOSS V. GASTRO INTESTINAL TRACT UPPER GI SERIES (Barium Swallow) xray visualization with contrast medium - Contr ast Medium: a. Gastrografin ± water soluble, use straw b. Barium - swallow ± milk sh ake like (use feeding bottle of pt) - then pt is ask to assume different positio ns to distribute dye @ esophagus purpose: to detect disorders of esophagus feces : ªchalky-whiteº after: instruct pt to take laxative to excrete dye
BARIUM ENEMA (for Lower GIT) involve rectal installation of barium; there is bal loon catheter inserted @ anus then barium is instilled and pt is asked to roll-o ver at different position then xray is taken to detect: hemorrhoids, diverculosi s, polyps and lesions; after, give laxative to excrete dye (bec dye is constipat ing) instruct also patient to inc oral fld intake
GUAIAC TEST to detect the presence of bleeding and inflammatory bowel condition like CANCER; (this can be refrigerated awaiting laboratory) specimen : stool AVOID the following 3 days B4 the test ± bec it can yield to FALSE (+) RESULT : Re d 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 ALERT: assess for allergy (epinephrine /benadryl) Post procedure: inc. oral fld intake ± to facilitate excretion of dye
GASTRIC ANALYSIS analysis of gastric secretion like HYDROCHLORIC ACID Lower Leve l 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 ZOLLINGER-ELLISON SYNDROME ± (+) Gastric Tumor b. WITH TUBE ± with the use of NGT then aspirate
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 an d Cirrhosis; ALERT: Check for Bleeding Time (N ± 1-9 mins) and 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 Position af ter : R side-lying position Things to report: s/s of SHOCK ± inc PR, dec BP Check v/s
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP) to visualize common bile d uct and pancreatic duct; invasive ± (+) consent;
NPO ± tube insertion; Tell pt that tere will be feeling of soreness a wk after the procedure
COLONOSCOPY visualization of colon to detect: inflammatory bowel condition Chron's Dses Diverticulitis Hemmorhoids Tumor Polyps - (+) Consent - NPO b4 - clear liquid diet ± 2days b4 the procedure position: Late ral or side lying position or L Lateral Sims VI. ENDOCRINE GLUCOSE TOLERANCE TEST to provide measure of bld sugar level at blood; Inform pt to have high CHO diet 2 days b4 the test; Instruct NPO a day b4 the test (npo p ost midnoc); Inc sugar level, therefore Diabetes ACTH STIMULATION TEST to detect presence of Addison's Dses specimen: blood pt is g iven dose of ACTH (not nore than 40ug/dl) if still dec despite ACTH administrati on, therefore Adrenal Insufficiency ± Addison's Dses
DEXAMETHASONE SUPRESSION TEST to detect endogenous depression ± depression resulti ng thru endocrine disorder pt is given dexa then 24hr urine specimen is collecte d; a dose of dexa will suppress the release of adrenal hormones; if despite dexa administration still increase adrenal hormones, therefore pt is suffering depre ssion
17 KETOSTEROID & 170 HCS use to detect the presence of Addison's & Cushing's Dses.
Addison's ± dec secretion of ketones Cushing's ± ince secretion of ketones Specimen: 24 hr urine
VANILLYLMANDELIC ACID TEST ± VMA Test bi-product of CATHECHOLAMINE Metabolism epinephrine norepinephrine inc if there is TUMOR (pheocromocytoma) of Adrenal Medulla N 2-7 mg/dl / 24hrs ± if inc, therefore tumor AVOID: vanilla containing food 3 day s b4 test ± RAIU 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 proce dures that uses contrast medium (ªNOº - angiogram test). ± bec it may yield to false ( -) result. SULKOWITCH'S TEST detect amount of calcium excreted at urine; if to tes t for hypercalcemia and hyperthyroidism - gather specimen b4 meals; to test for hypocalcemia and hypothyroidism ± gather after meals ice cream, coffee, chocolates
VII. 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 abnormality: lower than 1.005 ± diabetic insipidus higher than 1.030 ± diabetic mell itus (+) glucose ± infection, DM (+) CHON - PIH, kidney dses. Urine maybe refriger ated if waiting to be examined.
CULTURE & SENSITIVITY to detect infection prepare storage container
KUB xray of the kidneys, ureter and bladder - NO SPECIAL PREPARATION NEEDED IVP - xray of the kidneys, ureter and bladder - uses contrast medium/ dye - assess f or allergy, then inc. oral fld intake after - benadryl or epinephrine at bedside for allergic rxn - NPO POST MIDNOC, cleansing enema in AM
CYSTOSCOPY visualization of urinary bladder after : monitor I & O; note for s/s of bleeding
RENAL BIOPSY aspiration of tissues at kidney for biopsy to detect: a. malignancy / Ca b. malignant HPN c. kidney disorder note for s/s of bleeding
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 bl adder respond to distention after installation of flds; monitor I & O VIII. MUSCULO-SKELETAL ELECTROMYOGRAPHY to detect electrical activity of the muscle; (+) consent; to al ternately contract and release the muscle as needle is inserted HOLD muscle rela xant b4 the test
ARTHROCENTESIS aspiration of fluids at synovial space to detect abnormalities; c heck for order of analgesic; apply cold pack
ARTHROSCOPY - visualization of joints - KEEP TORNIQUET, ICE PACK and ANALGESIC a t bedside BONE SCAN detect rate of bone destruction or bone resorption for pt w/ osteoporosis; lie still during the procedure; PAINLESS AND NON INVASIVE
IX. MISCELLANEOUS BONE MARROW BIOPSY to check abnormalities at the b. marrow (eg. Leukemia) site : ILEAC REST (+) consent assess for bleeding sand bag at bedside (post procedure) ± for emergency use SCHILLING'S TEST specimen: 24hr urine test for VIT B12 deficiency; for pt w/ PERNI CIOUS ANEMEIA; pt is given oral VIT B12 then urine is collected, then NOTE for R ATE 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 excret ed.
URINE UROBILINOGEN to detect HEMOLYTIC DSES WITHOLD ALL MEDS ± 24hrs b4 the test B ENCE-JONES PROTEIN detect presence of MULTIPLE MYELOMA (malignancy of plasma cel ls); RELEASED by destroyed or damage bones
ROMBERG'S TEST check FUNX of CEREBELLUM; stand erect, close eyes, and observe for inability to maintain posture Swaying, therefore TUMOR at cerebellum) (if pt is
ERYTHROCYTE FRAGILITY TEST use to detect the rate of RBC DESTRUCTION in a hypoto nic
solution (RBC Lifespan: 120 days) if lifespan of RBC >120 days, therefore HEMOLYTIC ANEMIA (EX. SICKLE CELL)
HETEROPHIL ANTIBODY TEST detect presence of IgM w/c is related to Epstein Virus infection Epstein Virus Infection ± causative agent of infectious mononucleousis (ªkissing dse sº) mgt: AVOID SHARING of utensils and glass
LYMES DSES SEROLOGY detect presence of BORRELIA BURGDORFERI ± dses. Treatment: tetracycline causative agent of lyme's TIPS FOR DIAGNOSTIC PROCEDURE 2 moths old infant suspected of brocholitis is treated with oxygen therapy. Whic h 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 n
eedle 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 r
equire 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 follo wing: 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 d
one in a CT scan: ªa dye will be injected to meº. A pt is to have an upper GI series ± which statement shows that he understood the
instruction given : ªI will drink the dyeº. After liver biopsy, a potential complication: bleeding. MRI is the primary diagn
ostic tool for multiple scelosis bec it promotes visualization of plaques at the brain.
DAY 5 (8 Feb 2005) PHARMACOLOGY I. GENERAL CONSIDERATIONS · · · · · · ONLY RN's are allowed to administer (to include central line) 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 (ªleukocytopenia ± all PENIAº) 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 st oicism attitude MIDDLE EASTERNERS (they refuse meds if for the 1st time) 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 ST JOHN'S WORT anti-depressant (it funx like MAO inhibitor); - do not give to pt taking MAO VA LERIAN - sedative (used also as anti-anxiety agent) - adverse effects ± GI Irritat ion GINGCO BILOBA - blood thinner; - use to enhance bld circulation; - for pt w/ alzeimers - CONTRAINDICATED to pt with bleeding disorders
COMMON CONTRAINDICATIONS for HERBAL MEDS: NO HERBAL MEDS for pregnant client; NO HERBAL to lactating pt; NO HERBAL for tho se with severe kidney and liver disorder IV. THE CHECK PRINCIPLE C± HECKlassification (FOR WHAT?) ow will you know that he meds if effective (evaluation) xactly what time are you going to give it lient teach ing tips eys to giving it safely
Lactulose ± given to pt with hepatic enceph to dec ammonia absorption - s/e : diar rhea ANTABUSE (dizulfiram) ± most appropriate time to take meds : after 12hrs of a lcohol 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: The followi ng CANNOT be delegated: time, route, dosage and untoward reaction; treatment, administration, documentat ion of meds
PSYCHOTROPIC I. ANTIPSYCHOTIC major tranquilizer; for SCHIZOPHRENIA (pt has EXCESS DOPAMINE); plays as treatme nt to the symptoms NOT CURE to schizo ± meaning it modify the symptoms (target sym ptom: to decrease dopamine) Haldol Chlorpromazine Clozapine (chlozaril) Olanzapi ne (zyprexa) Risperdon BETS TO GIVE: after meals DOPAMINE ± neurotransmitter (faci litate the transmission of neurons) In SCHIZO there in INCREASE NEUROTANSMITTER. Signs & Symptoms: a. DELUSION ± ªFALSE BELIEFº b. HALUCINATION - hearing sounds c. LO OSENES OF ASSOCIATION ± shifting of topic CLIENT TEACHINGS: Report ADVERSE EFFECTS of ANTI-PSYCHOTICS ± which indicates agranulocytosis a. fever b. body malaise c. sore throat d. chills hyperpyrexia and muscle rigidity this indicates NEUROLEPTI C MALIGNANT SYNDROME (NMS) drug of choice: Parlodel, Dantrium ex.
Assess SIGNS and SYMPTOMS of PSEUDOPARKINSONISM a. mask-like face or expressionless face b. pill-rolling tremors c. cogwheel's rig idity or lead pipe rigidity AKATHESIA ± ªrestless leg syndromeº (I feel as if I have ants in my pants) DYSTONIA Av oid direct sunlight ± because meds photosensitivity Instruct pt to rise slowly ± to avoid orthostatic hypotension
Check: CBC, BP, AST/ALT To prevent pseudoparkinsonism, administer ANTIPARKINSONI AN agents IA. DOPAMINERGICS - ANTIPARKINSONIAN in schizo there is increase dopamine, therefore give antipsychotic to dec dopami ne then dec dopamine causes pseudoparkinsonism. Therefore give dopaminergic. ex. L-Dopa Levodopa Levodopa-Carbidopa
Effective if decrease in tremors and rigidity within 2-3 days; When to give: AFT ER MEALS; Health Teachings: a. dietary modification: AVOID CHON and Vit B6 - bec it decreases drug absorption b. check for ORTHOSTATIC HYPOTENSION and PALPITATI ON; c. check BP and PR IB. ANTICHOLINERGIC decrease ACETYLCHOLINE ex. Benadry Cogentin effective: if decrease tremors and rigidity; when to give: AFTER MEALS; Health Teachings: a. b. c. d. e. f. g. side effects: blurred vision (no driving); dry mouth ± suck on ice chips or hard c andy; palpitations ± check PR; constipation ± inc. roughage at diet; urinary retenti on NOT urinary frequency decrease BP ± rise slowly check BP, PR, ECG II. ANTI-ANXIETY minor tranquilizer decrease Reticular Activity System ± center of wakefulness ex. Valium, diazepam, Librium, Tranxene Effective: Decrease Anxiety, Decrease Muscle Spasm Promote Sleep (to pt w/ traction)
B4 MEALS ± because food delays absorption HEALTH TEACHINGS:
a. report ADVERSE EFFECT: PARADOXICAL REACTION ± opposite of side effects b. Dange r of Dependency c. AVOID: Caffeine, Alcohol ± it increase the depressant effect of the drug d. check RR ± it causes respiratory depression e. administer VALIUM sepa rately ± because it is incompatible with any drug ± use different syringe. III. ANTI-DEPRESSANT/MANIC a. b. c. d. TRICYCLICS MAO STIMULANTS SSRI PATIENT with DEPRESSION ± there is DECREASE norepinephrine and serotonin A. TRICYCLICS ± prevents the reabsorption of norepinephrine. Ex. Tofranil, Elavil Effective: If adequate sleep (8hrs only) Increase appetite AFTER MEALS Best given: 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. MAO INHIBITOR (MonoAmine Oxidase) prevents the destruction of NEUROTRANSMITTERs ex. Parnate, Nardil and Marplan Effective : if INCREASE SLEEP and APPETITE ± Give AFTER MEALS Hx Teachings:
AVOID ± TYRAMINE CONTAINING FOOD (1 day before FIRST DOSE and 14 days AFTER LAST DOSE)
Avocado, banana, cheese (cheddar, aged and swiss) COLA, CHICKEN LIVER SOY SAUCE RED WINE PICKLES ALLOWED: cheese ± cottage and cream, FRESH MEAT, VEGETABLES Check BP ± the drug can cause HYPERTENSIVE CRISIS ± occipital headache ± ªmy nape is achingº 2 WKS INTERVAL ± when shifting ANTI DEPRESSANT ± to avoid HYPERTENSIVE CRISIS ex . after MAO ± 2 wks rest then can give ST JOHN'S WOR T C. STIMULANTS (Ritalin, Dexedrine and Cylert) directly stimulates the CNS. Effective: Increase Appetite and Adequate sleep Best to Give: AFTER MEALS if b4 meals, it suppresses the appetite; give NOT BEYOND 2pm bec. it causes INSO MNIA ± 6 Hrs b4 bedtime; shld be given in the morning ± to avoid INSOMNIA COMPLICATIONS: growth suppression Hx Teachings:
provide intervals or intermittently to avoid growth suppression; check BP and PR D. SSRI (selective serotonin reuptake inhibitor) Ex. ZOLOFT, Prozac Adverse effects: s/e: DECREASE LIBIDO and Impotence GI III.1 ANTIMANIC Lithium (lithane, lithobid, escalith) Tegretol Depakine/ Depakote
A. LITHIUM it alters level of neurotransmitters effective if DECREASE HYPERACTIVITY give AF TER MEALS Hx Teachings: diet: High Na (6-10 gms) and High Fluid (3-4L) N Na ± 3 gms, N fluid intake 3L Basically, Lithium is a salt Report the ff s/s (NAVDA) Nausea Anorexia Vomiting Diarrhea Abdl Cramps
Report also: FINE HAND TREMORS progressing to COARSE HAND TREMORS, THIRST and ATAXIC - sign o f LITHIUM TOXICITY ± Dug of choice: MANNITOL DIAMOX Hx Teachings: · · · · Avoid activity that increase perspiration ± Na & H2o; Avoid caffeine; Monitor lith ium level Frequency of Lithium monitoring: ONCE A MONTH; (specimen: blood drawn in the morning b4 breakfast or at least 12 hrs after the last dose) NORMAL LITHIUM LEVEL: ACUTE DOSE Below 65 yo Above 65 yo .5 ± 1.5 mEq/L .6 ± 1.0 mEq/L MAINTENANCE DOSE .5 ± 1.2 mEq/L .4 - .8 mEq/L Lithium is effective with 10 ± 14 DAYS before it will reach its therapeutic level. CONTRAINDICATION OF LITHIUM: · · · Pregnancy; Lactating; Kidney disorder - if above s/s are (+) to patient, instead of lithium use TEGRETOL, DOPAKINE/ DE PAKOTE tegretol ± a/e : alopecia dopakine/ depakote - gingivitis ANTICONVULSANT (Tegretol and dilantin) for seizures, wherein there is abnormal discharge of impulse in the brain action : IT INHIBITS the seizure focus and discharge
effective: if (-) seizure given BEST AFTER MEALS ± (except for sedatives- like valium) MOST DRUGS THAT AFFECT CNS ARE BEST GIVEN AF TER MEALS TOO. NSG ALERT: · · · · Check : Report GINGIVITIS; Report S/S of Bone Marrow Depression ± pancy topenia (dec RBC & WBC); Instruct pt to use SOFT BRISTTLED TOOTHBRUSH; Instruct pt to MASSAGE GUMS and frequent oral hygiene CBC ± due to pancytopenia RBC, WBC an d Platelet label CHOLINESTERASE INHIBITORS For MYASTHENIA GRAVIS For ALZEIMER's DSES : Prostigmin (long acting) and Tensillon : Cognex (tacrine) and Aricept (short acting) Myasthenia Gravis ± there is decrease or absence of Acethylcholine (ACTH) ACTH is a neurotransmitter the delivers the order ex. Brain to muscle to contrac t/move. 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 disappe ar within 30 seconds ± it is MYASTHENIA GRAVIS) Drug Action: · · · · Increase muscle strength (ex. Increase chewing ability or able to c hew food forcefully) GIVE B4 MEALS or any activity; Meds is FOR LIFE; Report s/s of HEPATOXICITY ± RUQ pain of abdomen and JAUNDICE Antidote: ATSO4 ± it reverses the effect of anticholinesterase · · Check for LIVER FUN X TEST; Keep at bedside: endotracheal tube ± for resp. problem ANTICOAGULANT HEPARIN For ACUTE CASES of Manic Case Antidote: PROTAMINE SO4 Given SubQ (Lower Abdl Fat ) COUMADIN FOR MAINTENANCE or Chronic CASE Antidote: VIT K Oral LOVENOX Heparin Derivatives Antidote same w/ Heparin
Effective if (-) clot Give same time of day Report s/s of bleeding : Hemoptysis Hematemesis Onset: 2-5 days (maintenance case) Check PT (N 11-13 sec and INR 24 sec) HEPARIN: AVOID ± green leafy vegetables ± bec it is rich in Vit K and will counterac t the effect of anti coagulant. Therefore, diet of patient ± no appropriate. NSG A LERT: monitor PTT (N 60-70 SEC, TIL INR of 175), if more than INR - HOLD ªINRº ± refer s to the upper limit of meds from N value to the maximum dose COAGULATION PROCESS: Vitamin K dependent clotting factors thromboplastin PRO THROMBIN THROMBIN COUMADIN HEPARIN FIBRINOGEN 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 ± NOT to dissolve clot (only as THROMBOLYTIC ± meaning it prevents ENLARGEMENT and F ORMATION of CLOTS) can be given together ANTIARRYTHIMICS Ex. Quinidine (quinam) Side notes: Characteristics of HEART MUSCLE: a. CONDUCTIVITY ± ability to propagate impulses; b. AUTOMATICITY - ability of heart to initiate contraction; c. REFRACTORINESS ± ab ility of t heart to respond to stimulus while in the state of contraction; d. EX CITTABILITY - ability of the heart to be stimulated Inotropic effect - force of contraction or strength of myocardial contraction; C hromotropic Effect ± conduction of impulses; CHRONOTROPIC Effect - rate of contrac tion ANTIARRYTHMIC (quinidex, pronestyl) 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 whi ch 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; Give meds anytime; Health teachings: a. report CNS ± confusion, ataxia and headache GI - nausea, anor exia and vomiting b. RASH ± therefore SKIN TEST FIRST c. REPORT s/s of QUINIDINE T OXICITY ± tinnitus, hearing loss and visual disturbances d. check pt PR and ECG ± wa ves, rate and rhythm QUINIDINE PROCAINE LIDOCAINE Ventricular arrythmia For VENTRICULLAR & ATRIAL Fibrillation CARDIAC GLYCOSIDES increase force of contraction; 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 en ters and it will result to a more increase force of contraction due to Na and Ca pump conversion.) Effects: (+) INOTROPIC ± strengthen the force of contraction (-) CHRONOTROPIC ± decr ease rate of contraction DIGOXIN EFFECTIVE : ACTION it increase FORCE OF CONTRACTION : onset : 5 ± 20 mins same DIGITOXIN same 30 mins ± 2hrs Give after meals due to GI irritation 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;
Digitoxin ± liver ± AST/ ALT DIGIBIND ± antidote for digoxin (lanoxin) THERAPEUTIC LEVEL: a. Digoxin b. Digitoxin : .5 ± 2 ug/L : 14 ± 26 ug/L NITRATES (nitroglycerine) EFFECTS: don't give if pt taking VIAGRA ± it will result to FETAL HYPOTENSION dilatation of c oronary arteries and arterioles thereby resulting to DECREASE IN PRELOAD & AFTER LOAD. Decrease in Preload ± decrease in the amount of blood that goes to the LV; AFTERLO AD ± amount of resistance offered by blood vessels that heart shld overcome when p umping blood · · · · · · · · Effective if NEGATIVE ANGINAL PAIN; Give BEFORE any activity; Administered SUBLI NGUALLY (+ 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); Once the bottle is open, use the meds within 3-6 mos DO NOT REPORT THE FF: (expected s/s) Hypotension, Headache, facial flushing ªwhy i s my face red?º MUCOLYTICS (an antidote also for ACETAMINOPHEN TOXICITY) Ex. Mucomyst it decreases the viscosity of secretion; give meds anytime; client teaching: meds can be diluted w/ NSS or cola; Side effects: NAV + Rashes if no side effects, repeat dose in 1 hr BRONCHODILATORS (ex. TERBUTALINE ± brethine) dilates the bronchioles or airways; effective: if (-) bronchospasm; GIVEN in AM to decrease insomnia
REPORT THE FF: insomnia, tachycardia, palpitation-PR, + NAV Theophylline - N 10-20; - for ACUTE ATTACK and PREVENTION of ASTMA EXPECTORANT (robitussin) stimulates productive coughing; effective : (+) COUGHING & SECRETIONS give ANYTI ME; sideffects: ± NAV + DIZZINESS or drowsiness ± avoid activity that required alert ness (ex. Driving) ANTIBIOTICS bactericidal; effective: (-) infection; give ON EMPTY STOMACH ± B4 MEALS; Hx teach ings: REPORT rash, urticaria and ªSTRIDORº ± indicates airway obstruction; side effect s: NAVDA + GI Irritation I. PENICILLIN : antidote is EPINIPHRINE II. AMINOGLYCOSIDE (gentamycin) effectiv e: (-) infection ± give B4 meals; report the ff: OTOTOXICITY: ªI hear ringing in my earº NEPHROTOXICITY : ºoliguriaº NEUROTOXICITY : ªseizu resº III. check BUN, CREA (kidney funx test); check I & O (sign of nephrotoxicity) ANTINEO PLASTIC (adriamycin) for breast and ovarian CA; effective: (-) tumor size; GIVE IN ARM ± to prevent HEMMORRHAGIC CYSTITIS Hx Teachings: a. inc oral fluid intake ( 2-3L/day) ± cytotoxic prevention; b. monitor kidney funx ± I & O; THYROID AGENTS (synthroid, cytomel) for HYPOTHYROIDSM; effective: if Inc in T3 and T4 and NORMAL SLEEP; pt always sl eep, 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 d ata); Give round the clock; a. Report sore throat, fever, chills, body malaise b ecause meds cause AGRANULOCUYTOSIS; b. Report lethargy, bradycardia, and INCREAS E SLEEP ± indicates that pt is having HYPERTHYROIDISM; c. Diarrhea with metallic t aste ± sign of IODINE TOXICITY Health Teachings: ANTIDIABETICS (INSULIN) effective: N Blood sugar (80-120) for DM Type 1 (insulin dependent); give in AM b4 meals; check: a. instruct S/S OF HYPOGLYCEMIA ± dizziness/ drowsiness difficult y in problem solving decrease level of consciouness cold clammy skin 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 - lunch ti me Intermediate - late in the afternoon ± B4 dinner Long Acting - B4 Breakfast SULFONYLUREAS (Orinase) for DM type 2; stimulate pancreas to produce insulin; effective ± N bld sugar leve l; give b4 meals regularly; teachings: a. s/s of hypoglycemia; b. monitor renal funx test; c. antidote for hypoglycemia ± ORANGE JUICE (amphogel, tagamet) ANTACIDS ALUMINUM HYDROXIDE GEL ± antacid and it also dec phosphate level in pt renal failu re; Effective: dec phosphate (-) pain give on EMPTY STOMACH (1 hr b4 or 2hrs aft er meals); instruct pt to REPORT: muscle weakness in lower extremities ± indicates HYPOPHOSPATHEMIA administer with glass of water; check phosphate level and rena l funx test; assess for constipation
LAXATIVES (dulcolax) Colace Metamucil Dulcolax Lactulose ± stool softener - bulk forming - rapid acting - 15-30 mins effective : (+) BM; give AT HS (if NOT diagnostic procedure); give AFTER MEALS ±fo r dyspepsia; meds is given in short duration only because of dependency teaching s: a. b. c. d. e. be near or stay near CR; s/e: diarrhea; NO lactulose for pt w/ diarrhea; Causes hypokalemia ± therefore check electrolytes Increase fld intake ± t o avoid dehydration DIURETICS Target Organs a. Diamox ± exerts effect at Proximal Convuluted Tubules; b. Lasix ± a t Loop of Henle; c. Diuril ± at Distant Con. Tubules LOOP DIURETICS (lasix) - effe tctive: incrase urine output; - give in morning to prevent nocturia; - teachings : a. monitor for hypokalemia level and I & O; b. report muscle weakness; c. give K rich food ± banana, orange THIAZIDE (diuril) give in AM; monitor for hypokalemi a; check I & O, K level, PR and BP K-SPARRING (triamterene, aldactone) effective: inc. urine output; give in AM; te achings: monitor for HYPERKALEMIA check PR and K ANTIGOUT
PROBENECID COLCHICINE ALLOPURINOL - URICOSURIC - for ACUTE GOUT - for CHRONIC GOUT - promotes excretion of uric ac id - has anti-inflammatory effect by - prevents or dec formation preventing depo sition of u.acid of u. acid @ joints - s/effects: NAV + - NAV + Bldg and Bruisin g - dizziness/drowsiness Hypersensitivity agranulocytosis (check CBC) - ONSET: 8 -12 wks - ONSET: 1-3 wks TEACHINGS: a. Increase ORAL FLUID INTAKE; b. Monitor uric acid levels; MIOTICS (timoptic, piloca) DECREASE IOP (N12-21) for pt w/ glaucoma; Give ANYTIME ± but for LIFETIME; Teachin gs: a. it causes blurring of vision and brow pain; b. administer meds at lower c onjunctival sac; c. press the inner canthus for 1-2 mins to prevent systemic sid e 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 CARBONIC ANHYDRASE INHIBITORS (diamox) for GALAUCOMA ± lifetime; to decrease production of acqueous humor; effective: N I OP and Inc. urine output; effective to pt with MENIERE'S DSES ± dec vertigo teaching s: a. check urine output; b. report: s/s of dehydration bec of diuretic effect c . blurred vision d. monitor I & O and IOP ANTI-ACNE (acutane, retin-a) decrease sebaceous gland size; given in AM to prevent insomnia; avoid sunlight: photosensitivity pregnancy: fetotoxic - therefore check if pt is pregnant; check if pt has skin irritation ± may burn the skin TOCOLYTICS (Yutopar, MgSO4) relax the uterus; drug of choice for pre-term labor; effective: (-) pre-term or relaxed uterus;
give: ORAL ± B4 meals and IV ± anytime; teachings: a. signs of Ca Intoxication: hypo tension, hypothermia and hypocalcemia b. check bld pressure; urine output (N 30m l/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 Antidote: Calcium Gluconate OXYTOXIC PITOCIN METHERGIN To induce labor To prevent post partum hemorrhage Effective: Firm and Contracted Uterus Give anytime If IV, use ªpiggy backº Teachings: a. REPORT the ff: HYPOTENSIO N (due to inactivation of ANS ± neurological effect of drug); b. Headache c. Hyper tension (cardiovascular effect of the drug) d. Check BP, Uterine Contraction ± esp ecially the duration ± N 30-90 sec - report if beyond 90 sec ± sign of uterine hyper tonicity e. Check Force, Duration and Frequency of Uterine Contraction PROSTAGLANDIN (cytotec, E2gel) anti ulcer drug to dec gastric acidity; decrease ripening of the cervix w/c lead s to effacement then dilatation then abortion; give after meals; assess for diar rhea and gastric irritation; check for pregnancy bec it may cause abortion
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 Pt w/ PVC : bedside : XYLOCAINE Pt w/ COMPLE TE HEART BLOCK: give ATSO4 ± it increases HR 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 ga in, obesity and Inc appetite Pt is taking LEVODOPA ± observe for URINARY RETENTION ADREAMYCIN ± causes hemorrhagic cystitis DESMOPRESSIN ACETATE ± administered INTRAN ASALLY FESO4 ± shld be given w/ orange juice ASPIRIN I s given to pt w/ TIA ± to dec rease 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
TYPES OF PRECAUTION P AIDS (universal) x H yes GL yes GW yes M yes DIARRHEA HEPA B C MRSA (enteric) x yes yes x x A (enteric) x x x yes yes yes yes yes yes yes yes x yes yes x (universal) (universal) (contacts) (enteric) yes x yes yes yes yes yes x yes x MENINGITIS/SEPTIC SCABIES TB (contact)
yes yes yes yes yes (tb Precaution) yes yes x x yes PEDICULOSIS P ± private room H ± handwashing GL - gloves GW ± gown M - mask (contact) yes yes yes yes yes AIDS ± universal Norwalk Virus ± respiratory Hepa A ± contact MRSA ± contact Scabies ± con tact
Day 6 (Feb 9, 05) D.I.S.E.A.S.E.S (MEDICAL-SURGICAL NURSING) GENERAL CONSIDERATION · · Priority: Oxygenation The disorders result as alteration in the function of HEAR T (pump), BLOOD (transport mechanism of oxygen, nutrients, hormones & CO2) and B LOOD 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 stru ctures 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: observ e for PALLOR ± if (+) indicates ANEMIA for baby Nocturnal dyspnea ± diff. of breathi ng at night Paroxysmal ND ± when pt feels as if he's drowning HEART SOUNDS: S1 - normal ± ªlubbº S2 - -do- ªdubº in assessing S1 & S2 use BELL of steth (ABNORMAL for adult pt ± it indicates CHF or Aortic Stenosis) S3 - N for Pediatric pt Steth - BELL ± for LOW PITCH SOUND (ex. Murmur) Diaphragm ± for HIGH PITCH SOUND
SHOCK mp: decrease in circulating blood volume TYPES 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 vasomoto r collapse (vasomotor ± located @ medulla oblongata w/c is responsible for dilatation & const riction of bld vessels)
SEPTIC ± due to systemic infection (ex. Septicemia) TRIAD SYMPTOMS OF SHOCK a. Altered level of consciousness b. Hypotension; c. Tac hycardia and Tachypnea (dec bld circulation ± result to dec o2 in the brain); Patient in shock- there is also (+) pallor and (+) oliguria ± due to dec bld circu lation & narrowing of bld vessels Lab Data (to check bld volume circulation) ± che ck HEMATOCRIT (N-35-45%) - check Urine Output - check CVP Nsg Dx: FLD VOLUME DEF ICIT rel to dec in Circ Vol. Priority Intervention: Fld replacement (D5Lr, NSS. Bld Trans ± for jehova's use plasma expander) ANEMIA MP: Decrease RBC due to decrease production or increase destruction Risk Factors : 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)
IRON DEFICIENCY ANEMIA common in infants and children; characteristic of patient : chubby but pale they are also called ªmilk babiesº those baby 5 yo but still takin g milk (milk are poor source of iron) MP: Nutritional Deficiency S/S : Fatigue Fainting Forgetfulness Pallor, cold cla mmy skin Dyspnea (due to dec RBC) Lab data: Decrease in HgB (N male: 14-18, Fema le: 12-16) Characteristic of RBC: HYPOCHROMIC & MICROCYTIC Nsg Dx: Activity Intolerance 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 teeth if IM (inferon) ± ªZº track method (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 b. Diet: iron rich food ± (organ meat, dried foods, ªegg yolkº ± iron, ªegg whiteº ± CHON); c. provide patient with BED REST ± due to fatigue PERNICIOUS ANEMIA common in elderly; common in POST GATRIC SURGERY (intrinsic factor ± the one that absorb vit b12) Main Problem: Lack of INTRINSIC FACTOR at the stomach In elderly, there is that GASTRIC ATROPHY w/c leads to dec in the Intrinsic fact or S/S: 3F (fatigue, fainting, forgetfulness) Beefy Red Tongue or glossitis Peripheral N europathy (tingling sensation at lower extremities ± usually both legs are affecte d)
Lab Data: a. check Hgb b. SCHILLING'S TEST (24hr urine) c. RBC characteristic : MA CROCYTIC & HYPERCHROMIC Nsg Dx: Activity Intolerance Risk for Injury due to p. n europathy Priority Intervention: a. Correct the deficiency ± give Vit B12 b. Bed r est ± due to fatigue (IM, Once a month for lifetime); 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/da y) ± green leafy veg. (spinach) Nsg Dx: Activity Intolerance PI: (NO RISK FOR INJURY coz NO P. NEUROPATHY) Inc. folic acid in the diet ± g. leafy; Bed Rest SICKLE CELL ANEMIA autosomal recessive hereditary presence of ªS or Cº shape Hgb due to dec O2 N TRAIT TRANS 50% 25% 0 0 0 50% 50% 50% 100% (SICKLING OF RBC) STATUS
DSES TRANS 0 25% 50% 1 PARENT W/ TRAIT BOTH PARENTS w/ TRAIT I parent TRAIT, 1 DSES BOTH parents w/ D isease Risk Factors: Dehydration (dec in circ bld volume ± result in sickling of RBC); In fections 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 an d possible necrosis b. Spleenic Sequestration Crisis c. Aplastic/ Megaloblastic Crisis ± ± massive entrapment of red cells in the spleen & liver bone marrow depression w/c resulted to DEC RBC, WBC & PLATELET Lab Data: Sickledex Test (+) Turbid Solution Nsg Dx: Activity Intolerance Fld Vo lume Deficit Pain ± due to vasocclusive crisis PI: Hydration and relief of pain (inc oral fld intake) Prevent dehydration Meds for Pain ± Morphine SO4, acetaminophen Since HEREDITARY ± refer to geniticist APLASTIC ANEMIA MP: Hereditary (there is DECREASE IN RBC, WBC & PLATELET) Autoso mal Recessive S/S: 3Fs + Pallor + Dyspnea Risk for Infection (dec in RBC) Bleedi ng (dec in Platelet) Lab Data: HgB, CBC, Clotting Factors Platelet, Bleeding & C lotting time Nsg Dx: PI: Activity Intolerance (dec in RBC) Risk for Injury (dec in WBC and Platelet) Bld transfusion; Reverse Isolation; Genetic Counseling; Bed rest THALASEMIA Risk Factors: Common in Blacks, Italian, Greeks, Chinese, Indians MP: Hereditary Autosomal Dominant ± common in female and male There is a defect in po lypeptide Chain of HgB ± ALPA and ETA Chain ± there is RBC destruction Types: a. Minor Thalasemia Anemia ± mild anemia: 3Fs
b. Intermedia TA ± more severe anemia + Speenomegally Jaundice (inc deposition of iron @ tissue) Hemosidorosis c. Major TA ± severe anemia + Spleenomegally Lab Data : HgB Clotting and Bleeding Time Nsg Dx: PI : Activity Intolerance Risk for Inju ry Bld Transfusion, IVF Dietary supplements of Folic Acid and Iron Surgery (last resort) LEUKEMIA MP: proliferation of immature WBC Characterized by Remission and Exacerbation Ty pes: a. LYMPHOCYTIC ± common in young children (proliferation of lymphocytes) b. M YELOGENOUS ± adolescent and adult (proliferation of granulocytes) TRAID S/S: · · · Anemi a (initial) + 3Fs Bleeding Infection Lab Data: WBC ± hyperleukocytosis (150 ± 500,000K) ± expected NDx: Risk for Injury Act ivity Intolerance Risk for infection Bed rest Avoid Contact Sports Reverse Isola tion Blood transfusion Bone marrow transplant PI: IDIOPATHIC THROMBOCYTOPENIC PURPURA (ITP) or WERLHOF'S DSES common in BLACKS; cause: idiopathic
unknown (viral and autoimmune) s/s: petechiae ecchymosis hemorrhage (all signs of bleeding) (spontaneous bldg) lab data: Platelet Count of less than 20,000 (N 150,000 ± 450,000) Nsg Dx: Risk for Injury Fld Vol. Deficit PI : (due to bldg) SAFETY ±prevent bleeding Give pt platelet, IVF and Bld Transfusion Corticosteroids ± ªwonder drugsº HEMOPHILIA inherited ± bldg disorder TYPES: a. Hemo. A - deficiency in factor 8 b. Hemo. B - deficiency in Factor 9 c . Von Willebrand's Dses ± common in male and female HEMPPHILIA A and B - Autosomal R ecessive Link (from mother to male) Von W Dses - Autosomal Dominant ± Mother and Father S/S: Hemarthrosis ± Hematoma Hem aturia Hematemesis bldg between joints that usually affects ankle, knee and elbow joints; (above mentioned are signs of HEMORRHAGE) Lab Data : PROLONGED CLOTTING TIME Nsg Dx : Risk for Injury PI : SAFETY then RIC E (REST, IMMOBILIZE, COLD COMPRESS, ELEVATE) For JEHOVAH'S ± use plasma expander (cryoprecipitate) instead 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 patie nt 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 ªMY CHILD DRINKS 2 QUARTS OF MILK/DAYº; a 7 yo boy with HEMOPHILIA was admitted. MA NIFESTATION ± HEMARTHROSIS; w/c of the ff is EXPECTED
pt w/ IDA has NSG DX of ALTERED NUTRITION LESS THAN BODY REQUIREMENTS. w/c of th e 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 ALTERN ATING w/ activities; w/c of the ff is indicative of thrombocytopenia - HEMATURIA
CARDIOVASCULAR PEDIATRICS FETAL CIRCULATION 3 FETAL STRUCTRUES
PLACENTA UMBILICAL VEIN DUCTUS VENUSUS (functionally, closes at birth) LIVER UMBILICAL ARTERIES Vena Cava Right Atrium AORTA FORAMEN OVALE (functionally, closes at birth) LA R Ventricle L VENTRICLE LUNGS LV L ATRIUM P. ARTERY DUCTUS ARTERIOSUS (functionally closes by 3-4 days at birth) AORTA Therefore, if these 3 fetal structures will not close, CONGENITAL HEART DISEASE CONGENITAL HEART DISEASE ACYANOTIC HEART DSES CYANOTIC HEART DISEASE Dec Pulmonary Bld flow Obstructive CHD Decrease Pulmonary
Vent. Septal Defect (most common) Atrial Septal Defect Patent Ductus Arteriosus Pulmonary Stenosis Aortic Stenosis Coarctation of the Aorta Tetralogy of Fallot (most common) Transposition of the Great Vein Truncus Arteri osus Tricuspid Atresia Usually due to: Maternal Infection ± measles, c. pox Age 40 and above Medical Conditions ± DM Alcoho lism Signs and Symptoms: Difficulty feeding Retarded Growth Tachypnea/Tachycardia Frequent URTI ANS ± brow seating (check for ªmurmurº) Complication: CH Failure Lab Data: 2 D Echo CVA (due to plycythemia ± Inc RBC) Nsg Dx: Altered Tissue Perfusion PI : Oxygenation Surgery If < 2yrs old prepare the patient the moment the diagnosis was confirmed/ determ ined; 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 PATENT DUCTUS ARTERIOSUS connection problem : P Artery and Aorta ªmachinery-like murmurº (+) brow seating (+) retarded growth (+) tachycardia/ tachypnea 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 d efect ªboot-shape heartº tet spell ± squatting w/ cyanosis LAB DATA : 2 D-echo Complication : CVA ± check for RBC Count Nsg Dx : Risk for Inj ury PI : Oxygenation Position the Pt. : SQUATTING Surgery COARCTATION OF AORTA Higher BP in the Upper Extremities and Lower BP in the Lower Ext. Lab Data : BP, 2 D-Echo PI : Oxygenation Position the patient: Orthopneic or sem i ± fowler's position KAWASAKI'S DISEASE due to acute vasculitis (inflammation of bld vessels) of the heart; especially t o JAPANESE children and toddler 5yo and below S/S : High Spiking Fever for 5 Days Lymphadenopathy Strawberry Tongue Palmar and Feet Desquamation
Lab Data : Nsg Dx : No Specific Diagnostic test Check ECG Altered Tissue Perfusion Altered Thermoreg ulation Altered Skin Integrity High CHON Diet : TIPS FOR CARDIOVASCULAR ± PEDIA w/ of the ff is an OUTSTANDING SYMPTOM OF CARDIOVASCULAR PROBLEM in children ± dif ficulty 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 lowe r extremities towards the abodomen; a child who was brought in to a well baby cl inic turns cyanotic while crying ± REFER to the physician; the BLD VESSELS INVOLVE in PATENT DUCTUS ARTERIOSUS ± pulmonary artery and aorta; w/c of the ff data in m other health history indicates a risk factor for congenital heart disease ± ADVANC E AGE; when admitting a pt w/ suspected congenital heart disease, w/c interventi on is priority ± decreasing the metabolic demand of the heart
CORONARY ARTERY DISEASE (CAD) Main Problem : NARROWING and OBSTRUCTION of Coronary Arteries which could lead to HYPOXIA ± rever sible (which could further progress to ANGINA) and or ISCHEMIA ± irreversible (tha t could progress also to dev't. of SCAR FORMATION that can lead to MI). Risk Factors: Family History Atherosclerosis Smoking Elevated Cholesterol HPN
Obesity Physical Inactivity Stress CAD HYPOXIA ISCHEMIA NECROSIS ANGINA Myocardial Infarction ± ª jaw painº this leads to decrease O2 ± and will result to the conversion of aerobic metabolis m to anerobic thereby resulting to the production of LACTIC ACID ± that will stimu late the nerve ending of the heart w/ will produce/ result to PAIN that is preci pitated by: EATING Elimination ± due to valsalva manuever Exercise/effort/ exertio n Emotion Extreme Temperature ± ªcool tempº ± vasoconstriction sEx PAIN MTOCARDIAL INFACRTION · · · · · ANGINA Pain confined at sternal area Pain that resembles ªpressureº Relieved by rest & NITR OGLYCERIN SAME Precipitated by 6E's Pain that resembles ªindigestionº, crushing, excruxiating Pain ra diates to the L Jaw, L arm, L shoulder Relieved by SO4 Opiods (MORPHINE) Pain oc curs AFTER MEAL (post cebum) or AFTER ACTIVITY · S/S of above mentioned + SHOCK s/s ± esp to CARDIOGENIC SHOCK w/c is due to PUMP F ailure ± that leads to dec cardiac Output that leads further to CHF. SAME · ECG ± initial change is ST SEGMENT DEPRESSION w/
T WAVE INVERSION Increase CHOLESTEROL SAME HDL ± ªgoodº or Healthy ± liver for metabolis m ± 30-80 LDL - ªbadº ± peripheral vascular system ± bld vessels- 60-80 CARDIAC ENZYMES #1 Myoglobin Troponin CK ± within 2-3 days LDH 1&2 ± within 10-14 days SAME · Nsg Dx : PAIN Altered Tissue Perfusion Impaired Gas Exchange · Priority : Airway (Oxygenation) · Goal of CARE a. To decrease oxygen metabolic dem and - position : SEMI-FOWLER'S - administer O2 as ordered - administer meds: MI : Morphine SO4 ± monitor RR, effective : (-) pain, ANTIDOTE : Naloxone HCL ± Narcan AN GINA : Nitroglycerine ± dark container give b4 activity maximum of 3 doses, 5 mins interval effective: tingling sensation, sublingual provide rest ± due to pain b. Diet : Low Na and Low Cholesterol HEALTH TEACHINGS: Identify types of Angina: Stable Angina ± predictable ± angina that occurs w/ activity; Unpredictable ± relieved by Nitroglycerin; Variant/ Prinzmetal ± severe form of Angina; Nocturnal Angina ± o ccurs at night; Decubitus Angina ± when pt is lying down Intractable Angina ± unresp onsive to tx Post MI Angina For patient with MI ± focus on complications :
a. PVC or PVBeats ± defibrillation/ cardioversion b. Ventricullar Fibrillation ± Lid ocaine ± s/e ªrashesº CARDIOVERSION - synchronize - esp. for VTACH w/ PULSE DEFIBRILLATION - unsynchro nized - for VTACH w/o PULSE
SEX ± for pt w/ MI ± resume if pt tolerate 2-3 plights of stair w/o pain; - take med s b4 sex; - position during sex : passive ± let the girl do her share ACTIVITY ± adv ised pt to have frequent rest period; DIET : avoid PROCESSED FOODS; MILK Salty S ea 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 ± espe cially 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 oth er ªpulmonary s/sº ± ªcracklesº
RIGHT SIDED HF ± systemic effect ± distended jugular vein Ankle edema Ascites Hepatomegally LEFTS SIDED HF Lab Data : Swan Ganz PAP (N 20-30) PCWP (N 8-13) X-ray Nsg Dx : RIGHT SIDED HF CVP (N R ± 0-12, V Cava ± 5-12) X-ray Altered Tissue Perfusion Ineffective Breathing Pattern ± for LHF Fld Volume Excess ± for RHF Oxygenation Position: Semi-Fowler's Administer: Digoxin ± absorb in GI Vaso dilators Diuretics Morphine ± for CHF ± it causes pheriperal vasodilation by Decreas ing the amount blood going back to the heart. PRIORITY : DIET : LOW Na ± NO PMS HEALTH TEACHINGS : a. Activity ± rest b. dietary counseling ± N O PMS c. report s/s of complications DIGITALIS ± D. Toxicity: yellow vision; Muscl e weakness (hypokalemia) ± that can lead to arrythmia Dyspnea ± s/s of pulmonary ede ma; HYPERTENSION MP : blood pressure higher than 140/90 (hypertensive state) pre hypertensive phase PREGNANCY INDUCED HPN Elevation of BP that occurs after 20-24 (5 mos- age of viability) wks of gestati on 120/80, therefore N BP : 110/70 Risk Factors: if BP elevated B4 20-24 wks & cont after delivery ± CHRONIC HPN Levels of PIH
Common in BLACKS; Obesity Stress Smoking a. HYPERTENSIVE DISORDER OF PREGNANCY - INC. BP + EDEMA & Proteinuria (s/s of PRE-ECLAMPSIA) b. PRE-ECLAMPSIA S/S + convulsion, Abdl pain & Headache PHASE c. ECLAMPSIA + Ble eding = HELP SYNDROME - ECLAMPSIA TYPES:
a. b. c. d. ESSENTIAL HPN ± cause ± unknown BENIGN ± usually of long duration, onset is CHRONIC MA LIGNANT ± acute or abrupt onset, short in duration SECONDARY ± related to existing m edical condition HPN IN PREGNANCY ± usually related to generalized spasm of the arteries PRE-ECLAMPSIA TYPES: a. MILD b. SEVERE BP 140/90, PROTENURIA is <5mg/hr (N - .51GM) BP 160/90, PROTENURIA is >5mg/hr HEADACHE and ABDOMINAL PAIN ± s/s of ECLAMPSIA, indicative of impending convulsion . ECLAMPSIA + BLEEDING = HELP SYNDROME H ± emolysis E ± levated Liver Enzyme L ± ow P- l atelet (All are signs of bleeding) S/S of HPN: Headache Retinal Hemorrhage Edema above s/s can further lead to complications: C oronary artery dses CHF Chronic Renal Failure CVA Blood Pressure Elevated Choles terol For PIH : (+) Proteinuria, Inc BP and Inc Cholesterol LAB DATA: Nsg Dx: Altered Health Maintenance Risk for Injury PIORITY: How? Stabilize BP I. Non-Pharmacologic Features Stress Management Deep breathing Diet : Low Na/ Ch olesterol Position : if inc BP ± supine position II. PHARMACOLOGIC MEASURES Antihypertensive Diuretics Aspirin Antilipimic - simv astatin & lovastatin ± give after meal nighttime Monitor liver Funx test ± meds abov e are hepatotoxic
Pts w/ PIH meds: a. MgSo4 ± antidote is CAgluconate b. Darkened room ± to dec stimul us thereby preventing convulsion PERIPHERAL VASCULAR DISEASE Arterial Obstruction Color pallor Edema (-) or mild Nails brittle nails Pain int ermittent claudication Pulse (-) Temperature cold Ulcer dry & necrotic TYPES: BURGER'S DSES (THROMBO ANGITIS OBLITERANS) common : MALE FEMALE MALE Venous Obstruction ruddy (+) & severe N homan's sign (+) warm wet (pain @ gastrocnemeus area) RAYNAUDS ARTERIOSCLEROSIS OBLITERANS
AREA AFFECTED : Lower Ext. Upper Ext ± 97% 3% - lower ext Arteries ONLY Upper & Lower Ext Affects arteries and veins Arteries ONLY MP : ªAngitisº ± inflam. of Spasm of Arteries Arteries & veins of lower ext of Upper & lowe r ACUTE Hardening of arteries due to fatty deposits INTERMITTENT CHRONIC - (+) pain usually related to - (+) 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 pa in that is relieved by rest. - aggravated by smoking ± causes further narrowing of bld vessels WBC & ESR DOPPLER USG Inc Cholesterol and Ca LAB DATA : Inc Nsg Dx: Altered Tissue Perfusion same Pain -dosame -doPI : MEDS : Relief of Pain (for all types) -do-doAnticoagulants Vasodilators (papaverin ± pavabid) Antihypertensive DIET : Low Cholesterol VARICOSE VEIN THROBOPHLEBITIS PHLEBOTHROMBOSIS Clot weakening of venous valves; CLOT + Inflammation job related (prolong sitting/sta nding) pregnancy hereditary secondary to existing medical condition
s/s : dilated tortous vein dragging sensation ªheavinessº edema (unilateral/ bilater al) ± tape measure to monitor leg circumference Pain Lab data: 1. conservative test ± TRENDELENBURG TEST ± pt lie down, elevate/ raise the legs the n stand up and observe for bulging of vein; 2. DOPPLER USG Nsg Dx : PAIN Altered T issue Perfusion
Hx Teachings : · · · Elevate the legs above the heart; Use support stockings; Surgery ± vein ligation & stripping Sclero therapy ± injection of sclerosing agents to make wall stronger t hereby 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: Fusiform - entire wall is affected Dissecting - part of inn er intima and media was dissected w/c lead to the pushing Saccular S/S: Pulsatin g 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. Prepare pt for Surgery of tunica adventitia to bulge CARDIO-PULMONARY RESUSCITATION (CPR) indicated for cardiac arrest when pt is BREATHLESS and PULSELESS; shake the pt ± a re you ok? If breathless & pulseless then; ACTIVATE the EMS ± Help! CPR (1 or 2 re scuer : 15 : 2) In 1 minute, there will be 80 compression and 15 ± 20 rescue breat hs Depth of Compression : 11/2º ± 2º If too deep - it may fx the liver Effect of CPR : #1 (+) Pulse; #2 skin color 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 w as diagnosed w/ MI develop atrial fibrillation ± this may possibly lead to ± CEREBRA L EMBOLISM; A pt w/ CHF was admitted exhibiting confusion, disorientation, visua l disorders & hallucination ± the nurse best action is to ± CALL THE PHYSICIAN; A nu rse is assessing a pt w/ MI ± w/c of the ff is the characteristic of PAIN ± pain rad iates to the jaw; In utilizing mind over body principle for pt w/ HPN ± w/c interv ention is appropriate - relaxation and stress mgt; Pt exhibits intermittent clau dication ± another sign of peripheral dses is w/c of the ff ± tropic skin changes; F f MI, when shall I resume sexual activity? ± when you can climb 2 plights of stair s 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 exhibi ts 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 v ein RESPIRATORY General Consideration: use the DIAPHRAGM of the steth when assessing breath soun ds; 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 interf ere 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 ªRE TACHY TACHY D Cº
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
BIOTS ± increase in depth followed by apnea; - pt w/ neuro impairement Cheyne-Stro ke ± increase in rate and depth of breathing followed by apnea; - nero case Kussma uls ± deep rapid breathing; Apneustic ± forceful inspiration followed by slow expira tion ± dying patient At birth, the child can maintain temperature by burning brown fat ± and increase b urning ± bi products is Increase fatty acids that will cause acidosis ± that can wor sen the Resp. Distress Syndrome ± a group of symptoms (mgt: maintain temperature). HYPOVENTILATION Cause: Lack of O2 Effect: ACIDOSIS HYPERVENTILATION ALKALOSIS Cause : lack of CO2 ± the pt will decrease rate of breathing to save CO2. co2 then combi ne with H2O to form carbonic acid ± if inc, can lead to acidosis ± and the brain wil l compensate by hyperventilating ± and increase elimination of CO2 will cause ALKA LOSIS. APNEA OF INFANCY Occurs in Full Term Baby (37wks onwards) SIDS/ CRIB DEATH Usually occurs in Pre-term Risk Factors: s/s : episodes of APNEA, TACHYCARDIA and Cyanosis a. b. c. d. Pre-Term; Those w/ episodes of Apparent Life Threatening Events Siblings of thos e who died w/ SIDS (usually 2-3 sis/ bro ± died) Hypoventilation Dx Procedures: Cardioneumogram ± measures O2 Polysonography ABG Analysis Tx : · · · Administer Theophylline (N 10-20 mg/ml) S/Effects: NAV and Insomia Caffeine Assi st mother threu grieving process (esp to Apnea of Infancy) Hx Teaching : Teach parents CPR
ASTHMA MP : Inflammation of bronchioles that leads to excessive mucus production that r esulted to narrowing and obstruction. Risk Factors : Environmental factors Emoti on Effort/ Exercise S/S : WHEEZING sound ± due to obstruction Orthopnea Whitish Sp utum Pulmonary Funx test Incentive Spirometer Ineffective airway Clearance AIRWA Y Lab Data : Nsg Dx : PI : 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 CO 2 Nebulization Chest Physiotherapy ± b4 meals or at bed time High Fowlers Intermitte nt Positive Pressure Breathing Aerosol Liberal Fluid Intake Meds : Aminophylline Steroids Theophylline Histamine Antagonist Mucolytic Antibiotics Hx Teachings : Appropriate rest; Activity ± avoid those that will expose pt to all ergens; AVOID PROPANOLOL and ASPIRIN ± causes BRONCHOSPASM; Exercise ± ªblowing exerci sesº ± bubbles, trumpet CYSTIC FIBROSIS multi system dses (GI and Respiratory System) characterized by excessive mucus p roduction by exocrine glands. GI Autosomal Recessive TRAIT TRANSMISSION ± 50% Chance for DISEASE TRANSMISSION ± 25% Respiratory Hereditary For each pregnancy S/S : MECONIUM ILEUS ± within the 1st 24-36 hrs ± if baby fail to defecate ± suspect for CF; ABDL DISTENTION Malabsorption Syndrome ± STEATORRHEA ± foul-smelling stool w/ Inc F ats & Bulky Salty to Kiss ± bec skin becomes impermeable to Na
Common Complications: MALE ± because of thick mucus plug Aspermia ± low sperm count Sterility FEMALE ± Difficulty in conceiving Nsg Dx : Knowledge Deficit Altered Elimination A ltered Sexual Functioning Sweat Chloride Test ± N (if sweat) 10 ± 35 mg/dl ± INCREASE IF (+) CF (if serum) 90 ± 110 mg/dl -doLab Data : PI : since two system are affected: Respiratory Therapy ± blowing of trumpet, Incr ease Fluid Intake; GI Therapy ± Administer Pancreatic Enzyme (pancreatin, pancreas e, viocase) GIVEN WITH EACH MEALS Effective : if (-) fat at stool Hx Teaching : Refer parents to GENETICIST CROUP DISORDER ACUTE LARYNGITIS LTB (Laryngotracheal Bronchitis) RSV/ BRONCHIOLITIS (Respiratory Synctial Virus) common in TODDLER VIRAL Inflammation of LARYNX ªbarking-metallic coughº (-) FEVER (+ ) STRIDOR INFANTS & TODDLER VIRAL or BACTERIAL INFANTS usually (less than 6 mos) VIRAL Inflam. of LARYNX & TRACHEA Inflam. Of BRONCHIOLES ªharsh-brassy coughº (+) FEVER-lo w grade (+) STRIDOR ªparoxysmal-hacking coughº (+) FEVER-moderate (+) WHEEZING STRIDOR ± is present when the affected part is LARYNX. Lab data: Nsg Dx : PI : P Exam ABG's -do-doELIZA INEFFECTIVE AIRWAY CLEARANCE Airway ± Endotracheal Tube (Tracheostomy Set - #1) ± to facilitate airway; Humidity ± place infant in MIST TENT or CROUPETTE Nsg care:
change clothing frequently coz mist will dampen child clothings;
TOYS while inside the tent: PLASTIC TOYS ªno battery operated & no friction wheel toysº at HOME: we can use NIGHT or MOIST air outside and hot shower mist at the co mfort room ± for child to inhale Antibiotics ± Antiviral ± Ribavirin Hx Teachings : SYRUP OF IPECAC ± for Croup ± it indu ces vomiting- bec it will stop the spam thereby preventing further coughing. Chronic Obstructive Pulmonary Disease (COPD) MP : group of disorders of respiratory system that lead to obstruction or narrow ing of airways. BRONCHITIS ASTHMA EMPHYSEMA Over distention of Alveoli Risk Factors: (+) (+) (+) (+) (+) S/S: Inflammation of Bronchus Gelatinous sputum + ªRE TACHY TACHY D Cº Allergy Environmental factors Pollen Elevated Immunoglobulin E (IgE) Smoking (es p to passive smokers) RE TACHY TACHY D C + ªbarrel-shape testº ± there is an INCREASE in ANTERIOR and POSTER IOR 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 : AIRWAY 1-2 L/min; Meds: Bronchodilator ± Atr ovent
Exercise: Blowing; Rest periods in between activities During ACUTE attack, the POSITION OF CHOICE : ORTHOPNEIC PNEUMOTHORAX MP : partial or total collapse of lungs due to: Types : · · · S/S : Open Pneumothorax ± TRAUMA Spontaneous Pneumothorax - due to rupture of BLEB ± Tensi on Pneumothorax ± due to INCREASE IN TENSION over distention of alveoli Diminished Breath Sounds ± (-) b. sounds to area auscultated; (+) Dyspnea; (+) Res tlessness Impaired Gas Exchange Ineffective Breathing Pattern Nsg Dx : 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 consol idation of the lungs. LEGIONARES DSES ± acute bronchopneumonia in elderly, alcoholic & Immunosuppressed pt - management same w/ pna VIRAL PNA Fever : Cough : WBC : Lab Data : Nsg Dx : PI : · · · · · · (+) low-moderate BACTERIAL PNA (+) fever moderate-high (+) Non productive ± ªthin-wateryº (+) Productive ± ªrustyº No change or slight Xray and ABG' Impaired Gas Exchange ± due to exudation and consolidation of Alveoli Airway ± O2 P osition : Semi-fowler's or Orthopneic Bed Rest Inc Oral fluid intake Antibiotics T CDB (turning, coughing, & deep breathing) Elevated
TB HISTOPLASMOSIS MYCOBACTERIUM AVIUM COMPLEX Bacterial Bacterial Fungal (from HISTOPLASMA CAPSULATUM) from BIRD MANURE ± soil & transmitted thru inhalation Droplets & Airborne Droplets & Airborne Risk Factors: ASIAN IMMIGRANT IMMUNOSUPPRESSION MALNUTRITION Droplets & Airborne S/S : same: a to e + FOREST RELATED ACTIVITY Ask client if came from AVIARY same with TB a. initially asymptomatic; b. low grade fever that occurs in the afternoon; c. b ody malaise or weakness; d. coughing w/ bld streaked sputum; e. weight loss Lab Data : Histoplasmine Skin Test ± for Histoplasmosis Mantoux Test Xray ± confirmatory test Sputum - @ least 2 (-) to be effective Nsg Dx : Infection; Ineffective Breathing Pattern · MEDS : PROPHYLACTIVE TREATMENT OF TB ± Antiviral Meds INH for TWO WKS (take Vit B6 to avoid NEUROPATHY) Antibiotics Rifampicin INH Streptomycin Ethambutol take above meds for 6-12 moths to avoid resistance TIPS FOR RESPIRATORY you observed a nurse caring for a child in a CROUPETTE, if you are the nurse inc harge, what would be your #1 PRIORITY? ± changing the linens & clothings to keep c hild 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 expenditu re;
w/c of the ff intervention being carried out by LPN would require immediate inte rvention ± suctioning the pt for 20 seconds;
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 car ing for a pt w R Lower Lobe PNA shld put the pt in w/c of the ff position to enh ance postural drainage ± L Lateral w/ the Head Lower than the Trunk
DAY 7 (Feb 10, 2005) ENDOCRINE General Consideration Explain to the pt the MOST COMMON METHOD of assessment: a. Direct methods ± specimen : blood and urine b. Explain the methods of gathering t he specimen Consideration for PEDIATRIC PATIENT a. Involve the parents of the ch ild; b. Incorporate food preferences c. self insulin administration ± allowed to c hild 9 yo and above Reportable S/S : skin changes ± ªhave you noticed any change in your skin colorº (ªbronze skin pigmentation ± addison's dses) 2 servings of popcorn ± HOW MANY RICE TO GI VE UP = 1 if sandwich = 1 rice Inc. temperature S/S of Shock Specimen characteristic is usually affected by STR EE, DIET and Keypoints :
Normal Body Rhythm PKU MP : There is Absence of Phenylalamine Hydroxylase (the one that converts Phenyl alamine to Thyroxine ( a precursor to Melanin). Therefore (-) PH leads to accumu lation of phenylalanine at the brain that leads to Mental Retardation. S/S : Ini tially ± asymptomatic For OLDER CHILDREN : AUTOSOMAL RECESSIVE PATTERN of transmis sion (inherited) Since (-) melanine: Lab Data : Diarrhea Anorexis Lethargy Anemia Skin Rashes and seizure Musty odor of urine (d ue to phenyl pyruvic acid) hair : blonde Eyes: blue Fair Skin
Nsg Dx : GUTHRIE CAPILLARY BLD TEST ± initial screening ± done after the infant has ingested CHON for a minimum of of 24 hrs. Secondary screening : done when the infant is about 6wks old ± test fresh urine w/ PHENISTIX ± WHICH CHANGE COLOR Phenylalanine level greater than 8mg/dl ± diagnostic of PKU (4mg/dl ± indicative) Knowledge Deficit Altered Thought Process Risk For Injury PI : MEDS : Hx Teachings : Dietary Modification : LOW CHON and Low Phenylalanine Diet until adolescent or t il 10 yo ± bec b4 this time the brain mature Lofenalac ± 20-30mg/kg/day
Inform parents of the foods to be avoided; - prepare special education to parent s 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. LYMPHOCYTIC THYROIDITIS or JUVENILE HYPOTHYROIDISM Cause : MP : S/S : Autoimmune or genetics Decrease in T3 and T4 Dysphagia Enlarg e thyroid All s/s of hypothyroidism (decrease metabolism)
Nsg Dx : PI : Knowledge Deficit Activity Intolerance no tx because it regresses (only temporar y) spontaneously CRETENISM or CONGENITAL HYPOTHYROIDISM disorders related to absent or non-functioning thyroid; newborns are supplied wi th maternal thyroid hormones that last up to 3 mos; initially asymptomatic s/s b egins 2 ± 3 months behavioral s/s - apathy ± ªwell behaveº physical s/s ± large tongue & protrudes from mouth retarded growth intolerance to cold mental retardation Prevention: neonatal screening blood test; Without treatment, mental retardation and developmental delay will occur after age 3 mos; Decrease T3 and T4 Knowledge Deficit Risk for Injury Single morning dose of Synthroid fo r ªLIFEº ± oral thyroxine and Vit D as ordered to prevent M. retardation (adverse effect of meds : insomnia, tachycardia, and nervousness ± REPORT ASAP) Lab Data : Nsg Dx : Meds : 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 1. 2. 3. 4. 5. 6. 7. 8. 8 glands (ductless)- they secrete the hormone directly t o bld stream Pineal Gland Pituitary Gland Thyroid Gland Parathyroid Gland Thymus Gland Pancre as Adrenals Gonads (testes & ovaries) Glands PITUITARY THYROID UNDER Diabetes Insipidus Hypothroidism (Myxedema) OVER SIADH Hyperthyroidism (Graves, Basedows, Parrys)
PARATHYROID Pancreas ADRENALS Hypo DM Addison's Dses Hyper Cushings Conns PANCREAS Alpha Cells BETA CELLS Islets of Langerhans Glucagon Insulin (responsible for Decrease in blood sugar) Responsible in the increase Blood Sugar Absence (DM Type I) IDDM Juvenile Onset ± B4 age of 30 Adolescence to Early Adult Stage Pt is THIN Pt is KE TOSIS PRONE Deficiency (DM Type II) NIDDM Maturity Onset ± After age of 30; Pt is Obese NON-KETOSIS PRONE MODY ± DM III combines features of DM Type I & 2; Maturity Onset that occurs in young adult; O BESE, b4 age of 30 Non-Ketosis Prone GESTATIONAL DIABETES - occurs during pregnancy Types According to WHITE'S Classification TYPE ONSET DURATION
A B C D CHEMICAL DIABETES (+) Increase Bld Sugar After the age of 20 Bet 10 ± 19 yrs old Before 10 yrs old 1 0 years 10-19 years More than 20 yrs D1 D2 D3 D4 D5 Before 10 yrs old >20 yrs Beginning Retinopathy w/ calcification of arteries DM w/ HPN w/ calcification of Pelvic Arteries w/ nephropathy (Diabetes Nephropathy) Diabetes Cardiopathy Diabetes Retinopathy w/ Transplant of the Kidney E F H R T DIABETES MELLITUS MP : Deficiency in INSULIN ± either absence or deficiency of insulin that leads to alteration in the metabolism of CHO, CHON and FATS. Cause: unknown Autoimmune Genetic Stress Polydipsia Polyuria Polyphagia Wt loss R. factors : S/S : ± the stave cells send message to the brain to eat more Nsg Dx : PI : Knowledge Deficit Altered Nutrition 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 INTERMEDIATE SLOW INSULIN: Regular Insulin - BEFORE LUNCH NPH - LATE IN THE AFTERNOON/ AFTERNOON Protamine Zinc - DURING NIGHT Ultralente Best Site is ABDOMEN bec it is a NEUTRAL AREA
SUBQ ± 90 degree angle for insulin syringe 40 degree angle if non-insulin 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 1 0 PM to prevent hyperglycemia at early AM (tx: administer insulin)
Antidiabetic Agent; SOMOGYI Phenomenon ± rebound hyperglycemia Blood Sugar Monitoring ± in AM and supper time (2x a day); Ensure adequate food in take; Transplant of Pancreatic Cells; Exercise ± it will decrease insulin requirem ent Scrupulous foot care (in pregnancy/stress ± Increase insulin req) ± check up w/ podiatrist - foot powder, snugly fitting shoes, cut toe nail straigh t across - cut toe nail across - avoid going barefoot - always dry in between to es Modification for Pregnant Pt with DM · · +300Kcal; Insulin Requirement (dose will be adjusted on 2nd & 3rd Trimester); AM Dose: PM Dose: EFFECTS 2:1 for Regular to NPH 1:1 for R:NPH MOTHER Macrosomia Hyperglycemia Therefore pre-term birth Complication: Uterine Atony BABY Hypoglycemia RDS Congenital Defects COMPLICATION 1. Hypoglycemia (Insulin Reaction) - BLD SUGAR BELOW 50 DKA Risk Factors : Missed meals; Increase or Overdose of Insulin; Hyperglycemia (bld sugar level above 120) (Diabetic Coma) HHNK Overeating Decrease Insulin
S/S :
Too much Activity Inactivity Stress Infection Dizziness Drowsiness Difficulty Problem Solving Decrease Level of Consciousness + Cold Clammy Skin, Diaphoresis Lab Data : Below 50 Blood Sugar Level PI : Admin ister Simple Sugar (fructose-fruit juice) Hard Candy (not chocolate ± it is comple x sugar) If unconscious ± D50 DKA (Type 1) HHNK (Type 2) (Hyperglycemic Hyperosmolar Nonketotic Coma) S/S : 3 P's + Signs of Dehydration ± thirst & warm skin Hyperglycemia ªKussmaul Breathing + 3P's Thirst and warm skin Lab Data : PI : Increa se Bld Sugar #1 AIRWAY #2 Fluid Regular Insulin Risk for Injury More pronounced GI Disturbances Nsg Dx : 2. 3. 4. 5. 6. MICROANGIOPATHY - destruction of small blood vessels; hardening of arteries; ATHEROSCLEROSIS ± NEPHROPATHY OPTHALMOPATHY ± kidney damage; - w/c leads to cataract (eye exam annually); Peripheral Neuropathy or Autonomic Neuropathy there is poor nerve impulse transmission common manifestation : impotence DIABETES INSIPIDUS
(Pituitary Glands ± 3 lobes) ANTERIOR Secrete Tropic Hormones POSTERIOR Store Only (does not excrete) MIDDLE MSH (skin color)
FSH OXYTOCIN (follicle stimulating Hormone) ADH ACTH (adrenocorticotropic hormone)
LH (luteinizing hormone); GH (growth hormone); Prolactin PITUITARY GLAND ADH (anti Diuretic Hormone) ± retain h20 or flds 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 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 ± INTRANASALLYLypressin -doHow : Polyuria ± 21 L/day Polydypsia one hole of nose only Given as pt exhale to the mouth then inhale thru the nose then EXHALE to the mou th then give meds. Evaluate the effect of meds : Check Specific Gravity of Urine; Monitor I & O; Mo nitor V/S : assess for hypovolemic shock
SIADH excess ADH; MP : Fluid Retention ± result to DILUTIONAL HYPONATREMIA or H2O INTOXI CATION S/S : due to DECREASE NA ± this could lead to the ff: convulsion; seizure; HPN Above s/s could lead to decrease LOC LAB DATA : Decrease Na Level (<120 mEq/L) ± h yponatremia Nsg Dx : PI : FLUID VOLUME EXCESS FLUID RESTRICTION Drugs ± DIURETICS + ANTIHPN ± if cause by TUMOR ± PREPARE PT FOR SURGERY IF after surgery ± POLYURIA ± report ASAP ± s ign of DI PITUITARY GROWTH HORMONE DEFICIENCY DWARFISM - ªcongenitalº ex. MAHAL EXCESS B4 Closure of Growth Plate - ªgigantismº - long, slender extremities and Inc. in Hei ght ex. Marlo Aquino NANU'S SYNDROME (hereditary) After the Closer of Growth Plate - ªacromegallyº - there is coarsening of facial fea tures + enlargement of the digits (inc. shoe size) ex. Balingit Lab Data : INCREASE HUMAN GROWTH HORMONE
Increase Blood Sugar Nsg Dx : PI : Risk for Injury Safety Meds - Parlodel ± decrea se secretion of growth hormone If related to tumor : surgery GIGANTISM (long slender extremity) MARFAN SYNDROME (hereditary) MP : Cardio & Eye disorder Scoliosis (complication) KLINEFELTERS (chromosomal aberrations) MP : XXY Pattern (an extra X chromosome) X chromosome ± FEMALE COMPONENT of HUMAN BODY Problem is NON-DEVELOPMENT of SEX OR GAN ADRENAL/SUPRARENAL CORTEX (OUTER) RESPONSIBLE FOR SECRETION OF: MEDULLA (INNER) SECRETES THE FF: GLUCOCORTICOIDS MINERALOCORTICOIDS (ALDOSTERONE) EPINEPHRINE NOREPINEPHRINE GLUCONEOGENESIS STRESS RESPONSE ± ªfight or flightº - formation of sugar from Responsi ble for Na Retention new sources and K Excretion
DEFICIENCY IN GLUCO & MINERALO : EXCESS of GLUCO & MINERALO : ADDISON'S Dses CUSHING'S Dses/ syndrome EXCESS of MINERALOCORTICOIDS ONLY : CONN'S SYNDROME ADDISON'S CUSHING CONN'S INC. MINERALOCORTICOIDS - w/c cause K EXCRETION & Na RETENTION MP : Underactivity of the Adrenal Glands Overactivity of A. Glands (there is DEC G, M & SEX HORMONES) (there is INCREASE G & M) ADRENOCORTICAL INSU FFICIENCY
Excessive SECRETION of - coticosteriods especially the GLUCOCORTICOID CORTISOL Excessive ALDOSTERONE Secretion from A. Cortex Female (30-50) Related to Tumor Common: Male and Female Female (bet. Age 30-60) RF : Could be related to Surgery ± removal Related to Tumors Of Adrenal Gland and or Auto Immune Reaction S/S: Dec Bld Sugar (hypoglycemia) Dec Na (hyponatremia) Dec BP INC K (hyperkalemia) INC BP, NA ALL S/S OF CUSHINGS DEC K + EXCEPT HYPERGLYCEMIA Moonface, Hirsutism, Buffalo Hump, Pendulous Abdomen Hypertension Lability of Mood (mood swings) Pol yuria, Polydipsia Depression Cardiac Arrythmias ± due COMPENSATORY of MSH ± Inc w/c Trunkal Obesity / thin Extremities to dec K Leads to ªBronze-Like Skin Pigmentatio nº Hypertension Decrease Resistance to Infxn Hypotension, Weak Pulse Weight loss, Fatigue, Muscle weakness Nausea, Anorexia, Vomiting Hx of frequent Hypoglycemic Rxn Increase Cortisol Level Hypernatremia Hyperglycemia Hypokalemia Hypokalemia ± due metabolic Alkalosis Inc Urinary Aldosterone Level Decrease K Lab Data : Decrease Cortisol Level Hyponatremia Hypoglycemia Hyperkalemia Nsg Dx : Fluid Vol. Deficit Fld & E imbalance Fld Vol. Excess Fld & E imbalance Risk for Injury Fld & E Imbalance ADDISON'S PI : CUSHINGS CONN'S
Correct the imbalance ± IV Diet: Inc Na Dec K Administer Steroids (Fludocortisone) Admin. Hormone Replacement Therapy Cortisone ± give 2/3 of dose in AM 1/3 in afte rnoon Correct the imbalance - limit fld intake DIET : Low in Calories & Na High in CHO N, K, Ca & Vit D Check BP ± give antiHPN Limit the flds
Meds are FOR LIFE Prevent accident & Falls Diet : Low Na, Inc K
Prevent exposure to Infxn Provide rest periods ± prevent fatigue Monitor I & O, we igh Daily Protect client exposure to Infxn Minimize stress in environment MIO & weigh Dail y As Rx Monitor V/S, observe for HPN & edema Administer SPIRONOLACTONE (aldacton e) & K supplements Provide small, frequent feeding high in CHO, Na and CHON to prevent Hypoglycemia & Hyponatremia
Use of Table salt tablets (if Rx) or ingestion Surgery ± prepare pt if cause Of sa lty foods (potato chips) by pituitary tumor or hyperplasia if experiencing Inc. sweating Post Surgery: poor wound healing; report s/s of Addisonian Crisis ± sever e HYPOTENSION Avoidance of strenuous exercise esp in HOT WEATHER Meds: FOR LIFE Glucocorticoids Synthesis Inhibitors - Lysodren and Cytodren - prevents formatio n of Gluco¼
ADDISONIAN CRISIS
causes: s/s: severe exacerbation of Addison's dses caused by acute adrenal insuffieciency strenuous activity, infection, trauma, stress, failure to take RX Meds severe ge neralized muscle weakness severe hypotension hypovolemia, shock administer flds to treat vascular collapse IV glucocorticoids - Solu-Cortef and Vasopressors Mai ntain 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 PI : THYROID T3 & T4 - responsible for maintenance of METABOLISM Calcitonin - deposit Ca @ bones DEFICIENCY HYPOTHYROIDISM Adult: Myxedema Children: Cretenism Main Problem: EXCESS HYPERTHYROIDISM Grave's Disease, Basedow's or Parry's Dses Slowing of metabolic process caused by hypofunction of the Secretion of excessiv e 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 Causes: Excess in T3 and T4 S/S :
congenital surgery autoimmune genetic autoimmune tumor FACIAL EDEMA INTOLERANCE to COLD DECREASE v/s DECREASE GI Motility ± constipation HYPOactivity Increase Sleep ± hypersomnia Wt Gain in the presence of Dec Appetite Dry scaly skin, dry sparse hair, brittle nails EXOPTHALMUS (+) Goiter Hypermetabolic State INTOLERANCE to HEAT Inc V/S INC GI M otility - DIARRHEA Insomnia HYPERactivity WT LOSS even INC Appetite Warm smooth skin, fine soft hair Pliable nails Irritability, restlessness, agitation LAB DATA : Check TSH (increase) DECREASE T3 & T4 DECREASE RAIU (131) INCREASE Se rum Cholesterol Level DECREASE TSH INCREASE T3 & T4 INCREASE RAIU RADIOACTIVE IODINE UPTAKE (RAIU) ± administration of 123I or 131I orally; - perfor med to determine thyroid function (increase uptake ± indicated hyperthyroidism, mi nimal uptake may indicate ± hypothyroidism); nsg consideration : take a thorough h istory ± thyroid meds must be D/C 7-10 days b4 the test ± meds containing iodine cou gh preparations, and intake of iodine rich foods and test using iodine ± eg IVP ca n invalidate the test
NSG DX : Activity Intolerance ± due to Fatigue (fatigue ± due to hypometabolism) PI : HOW : Promote a EUTHYROID STATE a. THYROID SUPPLEMENT Synthroid, Cytomel ± lifet ime s/e: insomnia, palpitation nervousness b. DIET: low calorie c. Maintain vita l funx: correct hypothermia ± maintain adequate ventilation d. Provide comfortable , warm environment e. Increase flds and high fiber foods to prevent constipation ,. Admin stool softener as Rx f. Meds: thyroid hormone replacement ± take daily do se in AM to avoid insomnia Monitor THYROTOXICOSIS ± tachycardia Palpitations, naus ea, vomiting, diarrhea, Sweating, tremors, dyspnea Risk for Injury (bec of hyper ) same Admin AntiThyroid Meds ± for LIFE ex. PTU & Lugols Assign to private room awa y from excessive activity Quite & relaxing Activity Provide a COOL ENVIRONMENT D IET : High in CHO, CHON, CALORIES Vit & Minerals w/ supplemental feedings bet me als & at HS NO STIMULANTS tears Protect eyes w/ dark glasses & artificial Monitor for AGRANULOCYTOSIS (fever, Sore throat & skin rashes) ± if taking antithy roid meds. Prepare pt for surgery ± 2wks before SURGERY give LUGOL'S SOLUTION - it d ecrease size and vascularity of thyroid gland; - give w/ straw to avoid staining teeth; - can be diluted w/ H2O or orange/ apple juice; - report diarrhea & meta llic state Meds: a. Antithyroid Drugs ± Prophythiouracil and Tapazole - block synthesis of thyroid hor mone; - toxic effect include AGRANULOCYTOSIS b. Radioactive Isotope of Iodine (131) ± Radioactive Iodine Thrapy - given to dest roy the thyroid gland thereby decreasing Thyroid hormone production COMPLICATIONS OF THYROID SURGERY: MEMORRHAGE ± whether the dressing is dry or intact ± its not a confirmatory that the re is no bleeding. To check, slip your hands at the back of the neck (bec of pri nciple 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 ± du e to decrease in CA ± characterized by: a. tingling sensation ± fingers & lips b. Ch vostek's Sign ± facial muscle twitching on percussion of facial nerve c. Trousseau S ign ± carpopedal spasm THYROID CRISIS ± due to rebound hyperthyroidism Increase thyr oid hormone Increase HRate/palpitation Inc Temp - hyperthermia
PARATHYROID Parathormone HYPOPARATHYROIDISM Deficiency Inc CA in the Blood withdraws Ca @ bone to the bld EXCESS HYPERPARATHYROIDISM MP : Dec Ca (hypocalcemia) maybe hereditary, Or caused by accidental damage to or removal Of parathyroid glands during surger y eg thyroidectomy Increased secretion of PTH that result in altered state of Ca, Phospate & bone m etabolism S/S : Initial S/S: Tingling lips & Fingers Chvostek's Trousseau personality changes cardiac arrythmia s muscle pains Late S/S Bone Pain (esp Back Bone) Kidney Disorder ± kidney stones renal colic NAV, Constipation Lab Data : Decrease Ca Serum Phospate Inc Skeletal Xray ± reveal Inc Bone density Nsg Dx : PI : RISK FOR INJURY a. Safety b. Keep Ca supplement at Bedside c. Diet : Inc Ca ± spinach, sardines, seafoods d. Tracheo set ± deu to dec Ca ± Laryngospasm s ame same Inc Ca (N 4.5-5.5 mg/dl) Dec Serum Phospate Level xray ±reveal Bone Demineralizati on Inc Oral Fld intake ± due to renal calculi of having INC Ca Diet; Low Ca Surgery ± i f due to tumor
TIPS FOR ENDOCRINE
a child w/ PKU was admitted, w/c of the ff statements made by the mother indicat es a need for further instruction ± ªmy child loves to drink milkshakesº ± chon- w/c has INCREASE Phenylalanine; w/c of the ff if manifested by a child could be indicat ive of diabetes ± bed wetting; a common manifestation of HYPOGLYCEMIA ± shaky tremor s; a pt post thyroidectomy develops tetany, the nurse anticipates that the docto r will most likely order ± Ca Gluconate; rapid & deep breathing that occurs in dia betic pt is indicative of ± KETOACIDOSIS a pt is to receive NPH Insulin at 8AM, wh en shld the nurse expect to have hypoglycemia ± in the late afternoon; to determin e 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 statement s made by the diabetic pt would indicate the need for further teaching ± ªI will be hypoglycemic if I experience emotional stressº.
GENITO-URINARY General Consideration when performing assessment of Genito-urinary system, use o pen-ended question- bec some pt are not comfortable talking genitals; explain th e meaning of terminologies; ask the patient what symptoms bother him/her the mos t; Consideration for Pediatric Patient assess for history of sorethroat; bladder ca pacity increase with age infants ± about 65ml toddler ± 300-400 ml school age ± 800 ± 10 00 ml infants are unable to concentrate urine until the age of 1 ± therefore ± adequ ate milk intake if baby has 6-8 diapers /day; 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. frequency b. urgency c. hesitancy Reportab le s/s : peri orbital edema BP Oliguria Hematuria ± Early Stream Hematuria ± indicat e lesion at Urethra Late Stream ± indicate lesion at bladder
Key points : a. check for wt gain if >1lb/day ± indicative of fld retention b. cha racteristic of urine: color N - amber if pinkish ± bldg brownish ± flagyl orange ± rif ampicin c. s. gravity (N 1.010 ± 1.025) - if INCREASE - D. Insipidus DECREASE ± D. M ellitus
d. Increase glucose ± UTI e. Elevated CHON ± Nephrotic Syndrome or PIH Epispadias ± op ening at DORSAL portion Hypospadias ± opening at VENTRAL portion WILM'S TUMOR S/S : congenital tumor at the kidney common in L Kidney and children below 5 yo Unilateral Abdml Mass Hematuria HPN Lab Data : CT Scan IVP NO INAVSIVE LAB/ Procedure NO BIOPSY Nsg Dx : PI : Knowle dge Deficit Risk for Injury AVOID/ NO ABDOMINAL PALPATION Prepare pt for Surgery and Chemotherapy NEPHROTIC SYNDROME (therefore there is PROTEINURAI) causes: Autoimmune congenital AGN to Group A Beta Hemolytic Streptococus sorethroat MP : Altered Kidney Funx related to inability to retain CHON Destruction of Kidn ey Tissues related S/S EDEMA: Peri-orbital Edema but subside at the end of the day Periorbital but progresses to generalized at the end of th e day INCREASE BP Tea colored or Cola colored or Smoky BP : URINE : Decrease or N Frothy LAB DATA (+) Proteinuria, severe - >10mg in 24 hrs (+) Proteinuria - <10 mg/ 24hrs urine Nsg Dx : Fld Volume Excess Impaired Skin Integrity PI : Check BP Maintain Fld Balance Meds : NO Antihypertensive (+) Steroids (+) Antibi otics Antihypertensive Diuretics DIET : INCREASE CHON, Low Na LOW CHON and Na
POSITIONING : Turn Patient frequently ± because pt w/ edema are prone to skin inte grity like pressure sore formation CYSTITIS RF : Wearing silk underwear (does not absorb moist); - use COTTON Bubble bath Pr olong driving Common in FEMALE ± due to size (short) urethra S/S: FREQUENCY, URGEN CY & HESISTANCY + Burning sensation on urination (dysuria) LAB DATA : Nsg Dx : P I : Diet : Infection of the bladder Ascending infection caused by E. Coli (from feces) or P seudomonas Urinalysis ± to check for microorganism Altered Elimination Pattern Infection Treat for Infection ± antibiotics for 10-15 days ACID-ASH DIET ± give lemon juice or VIT C Bladder Analgesic (ex. PYRIDIUM ± ch can cause ORANGE COLORED URINE, effective : ( -) pain) Hx Teachings: Avoid bubble Bath No Silk underwear Inc. Fld Intake RENAL FAILURE ACUTE MP Sudden or Acute, Usually Reversible loss of Kidney Funx There is inability of ki dney to maintain fld & E balance CHRONIC IRREVERSIBLE kidney damage that leads to scar formation Causes PHASES :
Phases of ARF Pre-renal Factors ± those that dec bld circulating vol. ± SHOCK;Phase I: RENAL INSUF FICIENCY Intra-Renal ± dses condition of the kidney eg. AGN Post-Renal ± those that causes obstruction eg. Kidney stones Polyuria Nocturia Polydipsia PHASE II : MIL D RENAL DAMAGE (OLIGURIA) RENAL FAILURE All s/s + Anemia & HPN ESRD (1-2 yrs) Az otemia & Uremia ± accumulation of waste products ªuremic frostº ± skin pruritus same The re will be INC BUN & Crea OLIGURIC PHASE - decrease urine output that is less than 400 ml/24hr - Dec NA & Inc K DIURETIC PHASE - Inc urine output (4-5L/day) - Dec Na & K RECOVERY PHASE renal funx normalizes LAB DATA Increase BUN and Crea ± most sensitive Index
Nsg Dx Fld and E Imbalance Fld & E Imbalance Activity Intolerance PI : TO CORRECT THE IMBALANCE A. B. Fluid restriction; Meds : Diuretics Cardiac Glyco sides ± Digitalis Antihypertensive Fld restriction Amphogel ± to promote excretion o f Phospate Epogen ± Inc RBC synthesis Diuretics AntiHPN Diet: same C. DIET : Low CHON ± NO PMS DIALYSIS PERITONEAL Semi-permeable membrane: Abdomen (peritoneum) Use of Tenchkoff Catheter Teaching s:
HEMODIALYSIS Dialyzing machine Use of fistula or shunt anastomosis of artery & vein (internal access) ± less prone to infxn Report Infxn (abdomen: rigid, Solution : cloudy) Check BT and CT Check Temp of d ialyzing solution external access (more prone to infxn)
Complications of dialysis (report ASAP): 1. DISEQUILIBRIUM SYNDROME ± due to rapid removal of solutes (electrolytes and CHO N) s/s: GI ± nausea, vomiting, headache CNS - convulsion, seizures 2. DIALYSIS ENCEPHALOPATHY ± due to aluminum toxicity s/s: (+) dementia muscle abnormalities ± twitching seizures RENAL TRANSPLANT ± s/s of com plication : FLANK PAIN, FEVER, TENDERNESS, HPN - REPORT BPH S/S : Decrease size and force of urinary stream Nocturia Frequency, hesitancy an d urgency LAB DATA: Digital rectal exam ± once a yr for pt 40yo and above gloves, ky jelly position: Sim's Altered Elimination Pattern Prepare pt for surgery TURP ± n o incision Suprapubic Prostatectomy Retropubic -do Perineal -do- - common complic ation: IMPOTENCE due to nerve damage ªI am eager to have sex againº ± cannot be bec pt is impotence glandular enlargement of the prostrate common in males above 40 yr s old Nsg Dx : PI :
nsgcare : CBR for 2-3 days post surgery; NO LONG DRIVE/ SITTING; Ff up check up (if INC AC ID PHOSPATASE: Prostate CA) TIPS FOR GENITOR-URINARY A common sign of ARF ± OLIGURIA; After peritoneal dialysis, w/c of the ff is appro priate 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 exa m 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 di scomfort when performing EENT exam; Explain the methods of assessment to the pat ient; Consideration to Pediatric Patients Obtain feeding history (bec the type & techn iques differs) Obtain the diet hx of the pt and hx to URTI Involve the parents i n the assessment of the baby Reportable Signs and Symptoms
TINNITUS - ringing, buzzing or sea shell sound in the ear VERTIGO - Objective ± ªthe room is spinningº Subjective ± ªI feel that I am revolving/rotatingº
Hearing Loss Pain ± if pain subside or (-) ± rupture of ear drum Keypoints for Assessment Note for abnormal findings Document the subjective and objective complaints OTITIS MEDIA RF : Faulty feeding practices Swimming in dirty waters Upper Resp. Tract Infecti on S/S : PAIN ± Pulling Tugging Crying when lying on the affected ear Absence of p ain indicates rupture of Tympanic Membrane ± ear drum Lab Data : OTOSCOPY ± revealed ± reddened, bulging tympanic membrane infection of the middle ear Nsg Dx : PI : Infection Sensory ± Perception Alteration Treat Infection (antibiotics ± 7-10 days) ± if does not heal ± possible MYRINGOTOMY Hx Teaching : RIGHT POSITION while feeding
RETINOBLASTOMA S/S : congenital tumor of the retina; genetically transmitted; autosomal dominan t (common in MALE and FEMALE) LEUKOCORIA ± ªcat's eye reflexº - whitish or grayish disco loration of the pupil Diplopia and or Strabismus LAB DATA : Nsg Dx : Tx : PE Opt halmoscopy Knowledge Deficit Surgery ± Inoculation ± done b4 age of 3 (chemotherapy ± after surgery) Genticist RETINAL DETACHMENT RF: Aging (above 40) Related to trauma GLAUCOMA Aging (above 40) CATARACT Aging (above 70) Common in Blacks Related to Trauma Familial Predisposition Rel. to Diabetes Rel. to Steroids Rel. to Chromosomal Abberation - those with D. Syndrome are prone 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 manifestatio n as: VISUAL FLOATERS ± pt says: ªI see light structures Curtain like Floating spots Cobwebsº S/S : NO Pain Blurring of vision ± because of floaters Opthalmoscopy Risk for Injury Immediate Bed rest ± AFFECTED SIDE TOWARDS THE BED ± to allow the connect ion of DETACHED PART NO SUDDEN HEAD MOVEMENT AVOID reading (TV ± ALLOWED) Prepare Pt for Surgery: SCLERAL BUCKLING ± use of laser to reduce inflammation and when in flammation subside, the detached retina portion will be attached thru scar forma tion. Lab Data : Nsg Dx : PI : POST SURGERY : AVOID activity that requires BENDING, LIFTING, COUGHING; (No Bowling & shampooing of hair at sink)
REPORT SUDDEN eye pain ± indicative of bleeding/ hemorrhage 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 If Obstru ction related : could lead to CHRONIC OPEN ANGLE. If due to Forward displacement: can lead to ACUTE CLOSE ANGLE S/S : TUNNEL or Gu n Barrel Vision ± wherein there is loss of Peripheral Vision Halos around lights ± r ounded rings around eyes CLOSED ANGLE GLAUCOMA ± (+) pain OPEN ANGLE GLAUCOMA ± mini mal or (-) pain LAB DATA: Tonometry ± measures IOP (N12-21) ± PAINLESS ACUTE G ± as hi gh as 25; Chronic G - as high as 50 Nsg Dx : PI : Gonioscopy Opthalmoscopy Perim etry ± measures visual field Risk for Injury TO DECREASE IOP How: a. Administer MIOTICS (Pilocarpine, Tomolol, Diamox) ± for LI FE - it decrease the production of ACQEOUS HUMOR ± admin. At lower conjunctival sa c b. Prepare pt for Surgery : TRABECULOPLASTY ± a new pathway was created for the pa ssage of the blocked fluids; - Out-patient only (use of laser only) TRABECULECTOMY ± Hx Teachings : same w/ retinal detachment requires hospital admission for 1-2 days
CATARACT MP : Opacity of the Crystalline Lense S/S : Blurred Vision (Poor Color Perceptio n) NO PAIN LAB DATA: 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
CATARACT EXTRACTION ± Extra Capsular Cataract Extraction (ECCE) Intra Capsular Cataract Extraction (IC CE) ECCE ± removal of anterior part ICCE ± removal of entire capsule PHACOEMULSIFICATION - needle is inserted to lens and send vibration thereby crushing the cataract t hen suction it out PERIPHERAL IRIDECTOMY ± a whole is created then suctioning
Post Cataract Surgery ± NO SEX for 4-6 weeks Health teachings ± same w/ R. Detachmen t MENIERE'S DSES RF : High altitudes Aging Ototoxic Drugs Cause by an imbalance of EndoLymphatic Fluids in the inner ear Sensori-neural hearing loss ± since Inner ear was affected S/S : Tinnitus Hearing Loss + VERTIGO (only for M. DSES) Caloric Stimulant test OTOSCLEROSIS (hardening of the ears) Aging MP : Overgrowth of the stapes Conductive Hearing Loss - since middle ear was affected same same Lab Data: Weber's test ± lateralization of sound Rinne's ± bone conduction Audiometry (above test ± use of TUNING FORK) Nsg Dx : PI : Risk for Injury SAFETY (to prevent pt from falling: bedrest or supine ± danger of falls) Sensory Perceptualalteration Establish Communication Surgery : STAPEDECTOMY ± mobilization of stape
DIET : Meds : Effective : LOW NA (AVOID ± Alcohol & Caffeine containing food) AntiVertigo ± Diamox, Bonamine ( -) Vertigo/ Falls AVOID - driving PMS Sudden Head Movement Post Surgery Hx Teach ings: AVOID ± diving Small airplane Coughing Blowing of Nose Bending 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; w/c Nsg Dx is considered a priority for a pt with Meniere's Dses ± Ri sk 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 manifestation of Retinoblastoma ± Cat's E ye Reflex; The parents of the pt w/ retinoblastoma must be referred to - GENETIC IST
GASTROINTESTINAL GENERAL CONSIDERATION
Provide privacy Ask the pt when he 1st notice the S/S Eg. LIVER CIRRHOSIS ± when d id 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 tha n 6hrs) ± R/O rupture of the bowel Tarry Stool ± indicates bldg (upper GI) Fever, Ta chycardia, Dehydration ± indicative of SHOCK Hypotention KEPOINTS¼ Bowel Sounds (che ck 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 sou nd Ex. ªbruitº ± abnormal vascular sound w/c indicate abdml aortic aneurysm DIARRHEA/ AGE 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 : Fr equent stools Sign of DHN ± sunken fontannels Poor Skin Turgor Absence of Tears (f or 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) LAB DA TA : Stool Exam ± to check for bacteria Nsg Dx : Diarrhea Fluid Volume Deficit Pla ce pt on ENTERIC ISOLATION PRECAUTION ± while waiting for lab result (handwashing & gloves ONLY) PI :
CHALASIA GERD CONGENITAL WEAKNESS OF THE CARDIAC SPHINCTER S/S: vomiting - NON-BILE-STAINED Hear-burn due to Reflux of Acid Complication : METABOLIC Acidosis BARRETT'S ESOPHAGUS LAB DATA : Upper GI Series ( Ba Swallow) Gastroscopy Esophagoscopy do do do same same - damage to mucosal lining of lower esophageal mucosa w/c can lead to esophageal CA Nsg Dx : Altered Nutrition Less Than Body Requirement Flds & E Imbalance PI : In sure Adequate Nutrition Position: Place pt in UPRIGHT ± to avoid vomiting (if BABY: use HARNESS or PRONE w/ HEAD UP POSITION)
Administer flds Antibiotics/ Antidiarrheals ( dosage: if less than 10 kg, theref ore X100) Health teachings ± crackers, juice, water Feeding : Thickened Prepare pt for surgery : NISSINFUNDOPLICATION ± part of fundus will be sutured to esophageal area to tighten Effective: if (-) vomiting and(-) reflux and heartburn POISONING INTERVENTION: a. CALL poison control center; b. MINIMIZE EXPOSURE ± remove pt from the scene c. IDENTIFY the type of poison ªif unknown substance was takenº ± bring bot tle or foil for proper identification TYPES:
CORROSIVE ± ªDO NOT INDUCE VOMITINGº Management: NEUTRALIZE the poison If STRONG ACID ± give WEAK BASE (eg. ACID ± give MILK) IF STRONG BASE ± use weak ACID by using vinegar
NON-CORROSIVE ± induce vomiting by stimulating GAG REFLEX How: a. b. Use fingers or tongue blade Syrup of Ipecac ± administer w/ glass of H2O ± make sure that all taken will be vomited ± bec it is cardiotoxic (after 1hr ± can repeat) dos age: CHILDREN ± 15 ML ADULT - 30 ML CLEFT
LIP MP: Non-fusion of facial process PALATE Non-fusion of Palative Processess (soft & hard) (congenital) Nsg Dx : Altered Nutrition Risk for Aspiration Body Image Disturban ce PI : Nutrition Safety Prepare for Surgery Chiloplasty - for 10wks old 10 lbs 10gms/hgb 10,000 WBC Post Surgery: (congenital) Surgery : Palate Uranoplasty - if child is 15-18 mos 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/ c up Refer pt to: SPEECH THERAPIST, AUDIOLOGIST & PSYCHOLOGIST PYLORIC STENOSIS S/S : congenital hypertrophy (ªkumapalº) of the pyloric sphincter (bet stomach & intestine) · 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 AFTE R 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 ± (+) ªstring signº NSg Dx : Altered Nutrition Fluid Vol Deficit Fld and E imbalance Nutrition Surgery ± FREDET-RAMSTEDT or PYLOROMYOTOMY PI : ± incision at pyloric sphincter CELIAC DISEASE GLUTEN ±INDUCED ENETEROPATHY
MP : Genetic predisposition Life-time disorder Intolerance to GLUTEN OUTSTANDING S/S : Malabsorption Syndrome-crisis Abdl Enlargement ± this can be tri ggered by INFECTION & Fld and E imbalance Anorexia Anemia - there will be SEVERE DHN LAB DATA : Nsg Dx : PI : Diagnostic Test : GLUTEN CHALLENGE ± 3-4 mos ± give gl uten rich food And if there is malabsorption, therefore (+) CDses Altered Nutrit ion Dietary Modification : AVOID GLTUEN RICH FOOD : ALLOWED : Rice, cereals, corn, soy beans Barley, rice, oats, wheat Commercially prepared cakes are made of wheat ± AVOID Ok or allowed: if pt say ªI wi ll prepare a homemade cakeº AVOID : spaghetti, macaroni, sausage, luncheon meat, h otdog HIRSCHPRUNG'S DISEASE MP : (AGANGLIONIC MEGACOLON) Absence of parasympathetic nerve fibers in a portion of a colon dilation, abdomi nal distention and pellet-like or ribbon-like stool. Patient ± meconium ileus & constipation ± HALLMARK SIGN LAB DATA : BA Enema Nsg Dx : Diet : Tx : Meds : Altered Ellimination High Fiber Increase fluids Give Enema Laxative Surgery ± SOAVE Surgery ± resection with end to end pull through INTUSSUCEPTION MP : There is telescoping of a part of a colon which leads to inflammation and e dema
S/S : ªsausage-shape massº Abdominal distention ªDance signº ± the R lower portion of the colon becomes empty Vomiting : BILE-STAINED Constipation LAB DATA : Ba Enema: if for D IAGNOSTIC : it outlines the area involve if for THERAPEUTIC : it reduces intussu ception by means of hydrostatic pressure Nsg Dx : Diet : Tx : Constipation Alter ed Elimination Inc. Flds. High Fiber wonder drugs ± steroid surgery TRACHEOESOPHAGEAL FISTULA (TEF) MP : Failure of the esophagus to develop as a continous process Types : AF1 AF2 AF3 AF4 AF5 AF6 esophagus NOT connected w/ abdomen/stomach esophagus attached to trachea (when pt eat, it goes to the lungs) stomach connects w/ trachea stomach & esophagus connected stomach, eso and trachea are connected separated properly
Atresia ± ªnarrowingº Fistula ± connection S/S : Excessive Drooling ± danger in aspiration (avoid glucose water as initial feeding ± use sterile H2O instead.) Coughing, Chocking Cyanosis LAB DATA : Nsg Dx : PI : Lateral Neck Xray ± to check the esophagus Risk for Aspiration Safety Airway Keep child NPO ± just give pacifie r Surgery (if feeding OK ± use sterile H2o instead NOT GLUCOSE) Tx : TIPS FOR GASTRO ± PEDIA w/c of the ff signs if manifested by a child post tonsillectomy needs to be repo rted ± 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 i s important ± weighing pt daily for wt loss; w/c of the ff will the nurse expect t o observe in a child who loss fluid due to diarrhea ± flushed dry skin; the most a ppropriate 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 manifestatio n 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 sufferi ng from celiac dses ± intolerance to gluten
PEPTIC ULCER RF : Stress Smoking Salicylates or NSAIDS Helicobacter Pylori Zollinger-Ellison Syndrome (gastinoma) ± tumor of the stomach ± GASTRIC RF : MP : same Weakened Mucosa Common in Female Below 65 Inc risk for CA due to increase HCL acid ESOPHAGEAL same DUODENAL Excessive HCL Acid Common in Male 65 yo & above OUSTANDING S/S: PAIN ± aching, burning, gnawing PAIN ± 30mins ± 1hr post meal PAIN at daytime Pain relieved by vomiting - severe bleeding ± ªshockº 2-3hrs after meal Nightime Pain relieved by eating HEMATEMESIS (vomiting of bloo d) Also related as hyperacidity LAB DATA : GASTRIC Analysis (diamox blue ± urine) Gastroscopy BA Swallow HgB Hct Nsg Dx : PI : PAIN Relief of Pain Meds : ANTACIDS: Maalox ± it NEUTRALIZE HCL Acid; RANITIDINE - it DECREASE HCL Acid; SUCRALFATE - i t COATS the GIT NO ASPIRIN Diet : BLAND DIET ± NO SPICY, fried, raw fruits and vegetables
(EXCEPT: avocado, banana & pineapple) GASTRIC SURGERY VAGOTOMY PARTIAL GATRECTOMY ± Billroth I (BI) and Billroth II (BII) TOATAL GASTREC TOMY BI ± gastrodoudenostmy ± duodenum and stomach BII ± gastrojejunostomy ± stomach and jeju num COMPLICATIONS: PERNICIOUS ANEMIA ± due to decrease INTRINSIC FACTOR w/c came from stomach; DUMPIN
G 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 PANCA KE, 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 ± becau se it delays the emptying of the stomach LOW CHO Lie down ± after eating INFLAMMATORY BOWEL CONDITION ULCERATIVE COLITIS DIVERTICULITIS CROHN'S DSES (Regional Enteritis) RF : With familial Predisposition Common in those LOW FIBER Diet Related to Gene tics Smoking as Protective Effect Common in Aging Common in Obsessive-Compulsive Or Stress Related or to ªperfectionistº MP : Inflammation @ large Intestine Inflam @ L Intes. ± Specifically @ recto-sigmoid colon at DIVERTICULUM S/S : DIARRHEA FEV ER (15-20x/day) bloody mucoid (+) same diarrhea & constipation (+) LLQ Inflam of small & large intestine same 3-4x/day (+) RLQ CRAMPY ABDL PAIN LLQ (Rigidity (REPORT ASAP) ±sign of colon rupture) LAB DATA: BA ENEMA Colonoscopy Stool Exam PAIN Altere Elimination: Diarrhea Nsg Dx : PI : Relieve Pain Meds: Steroids
Anticholinergic Antidiarrheals Antispasmodic DIET : Low Fiber and Low Residue ± fo r Ulcerative and Chron's Diverticulosis ± High Fiber/residue ± allowed: vegetables Low residue ± (no vegetables) SURGERY : Colostomy ± irrigate Ileostomy ± no need for irri gation Characteristic of N Colostomy ± REDDISH or PINKISH EDEMATOUS MOIST N elevation from skin: 2.5 cm Diameter : 5cm When to empty colostomy: when 1/3 ± ½ full (EMPTY DO NOT CHANGE) When to change C. B ag : 48hrs or 3x a wk BEST TIME TO DO COLOSTOMY CARE ± at home, while in the bathr oom STOP colostomy irrigation if patient (+) ABDOMINAL CRAMPS HEMORRHOIDS MP RF PREGNANCY PROLONGED STANDING PORTAL HPN ± hepatic enceph and liver cirrhosis Varic osities of the ANAL SPINCHTER GRADE I II III IV Small Area Large Area ± reduces spontaneously Entire Area ± manual reduc tion Entire Area ± irreducible TYPES INTERNAL H ± above the spinchter EXTERNAL H ± below the spinchter S/S Pruritus Pain Bleeding Sigmoidoscopy Proctoscopy P Exam Altered Elimination LAB DATA Nsg Dx PI Diet : High Fiber Avoid Spicy PAIN ± use SITZ BATH (48 degree C ± temp of H2o) - emerge up to pelvic area with ice pack at head to prevent dizziness STOOL SOFTENER SURGERY PANCREATITIS RF AUTODESTRUCTION OR AUTODIGESTION of the pancreas #1 Alcoholism #2 autoimmune High Fat Diet Biliary Dses PAIN @ peri-umbilical are a or epigastric that radiates to peri-umbilical area SS
GREY TURNER SIGN ± pain w/ bluish discoloration at flank area; CULLEN'S SIGN ± pain w/ bluish discoloration @ umbilicus NAUSEA & VOMITING SHOCK ± as complication LAB DA TA Nsg Dx PI Elevated Serum Amylase (N56-190 u/L that normalize in 2 wks) PAIN R elieve PAIN Meds: DEMEROL ± DRUG OF CHOICE AVOID MORPHINE ± it causes more pain bec it will causes spasm to the spinchter of oddi DIET LOW FAT AVOID alcohol CHOLELITHIASIS Combine or usually come together in a pt CHOLECYSTITIS Stone in gall bladder Inflammation of the G. bladder RF Fat Female Fertile Forty flatulence same S/S R UQ Pain radiating to R shoulder or R Scapula ± usually precipitated by FATTY INT AKE GI S/S ± NAV diarrhea and Jaundice URINE: dark colored STOOL : ªclay-coloredº or g rayish ± alcoholic stool LAB DATA Increase AMYLASE, WBC, FATS Increase Liver Fnx test USG PAIN Relief of Pain meds : DEMEROL diet: LOW FAT surgery : 1) LAP. CHOLE ± 4 small incision, CO2 insufflat ion 2-3 days after ± discharge pt and back to ADL 1 WK after ± pt can lift weight 2) CHOLECYSTECTOMY ± R SUBCOASTAL - complication: ªPneumoniaº ± report rusty-colored sputu m hx teaching: TURNING, COUGHING, DEEP BREATHING Nsg Dx PI HEPATITIS MP TYPES A Infectious Fecal-oral Inflammation of the Liver B SERUM C D POST TRANSFUSION Non A & B E DELTA HEPA Post Hepa B ENTERICALLY-TRANSMITTED Fecal-oral bld, body flds
2-6 wks 6wks-6mos 70-80 days 6wks-6mos (Hepa A & B Combination STAGES OF HEPA B
PRE-ICTERIC - 1-2 days : S/S NAVDA ± NO jaundice yet; ICTERIC - 2-4 wks w/ jaundic e; POST ICTERIC - 2-4 mos s/s subside Increase Liver Funx Test (Inc AST/ ALT) He pa A ± Inc HaV Hepa B ± HbsAg Infection Alt Skin Integrity Body Image Disturbance Tx for Infection a. Meds : HEPATOPROTECTORS DIURETICS b. Diet : High Calorie Low F at Isolation : A & E ± Enteric B, C, D ± Universal Lab data Nsg Dx PI COMPLICATION Liver Cirrhosis LIVER CIRRHOSIS - scarring of liver tissues TYPES LAENNE'S Due to alcoholism BILIARY CARDIAC POST NECROTIC due to Hepatitis Due to biliary Disorder due to CHF S/S ± are related to 3 FUNXs of the LIVER
MANUFACTURES : METABOLIZES: STORES : bile, immunoglubolin, & clotting factors CHO, Fats, CHON, Alcohol and Drugs Vita mins & Minerals Signs and symptoms a. b. c. d. LAB DATA pt prone to bleeding; malnutrition ± no cho metabolize edema ± due to fld retention (bec of dec albumin) Flds & e imbalance Increase Liver Funx Test Liver Biopsy
Nsg Dx Risk for Injury Fld & E imbalance Fld Vol Excess Altered Nutrition SAFETY HOW? PI
Meds: Diuretics ± due to fld retention ANTIHPN ± due to portal HPN Clotting factors : Coag ulants ± give Vit K (to avoid bleeding) LOW CHON or CHON to Tolerance Or High Biol ogic Value CHON ± good quality CHON (eg poultry products)
Diet :
SURGERY : Liver Transplant COMPLICATIONS: a. HEPATIC EBCEPHALOPATHY ± accumulation of ammonia ± toxic to brain s/s: PERSONALITY CHANGES DECREASE LOC or irritability/ restlessness - facilitate excretion of ammonia by acidifying the colon - common s/e : DIARRHE A DRUG OF CHOICE : Neomycin, Lactulose b. ASCITIS ± accumulation of fluids at the abdomen s/s : wt gain Increase abdl girth ± ªI cannot button my pants anymoreº (fluids) management: abdominal paracentesis ± aspiration of fluids from the peritoneum - co mplication: chance for infection & shock pt preparation: #1 instruct pt to void; #2 position: sitting the evaluate the WE IGHT, ABDL GIRTH & REPSIRATION effective if : Pt decrease wt of 5 lbs and decrease or N RR c. BLEEDING ESOPHAGEAL VARICES ± DUE TO portal HPN Lab data Sengstaken Blakemore Tube ± 48 hrs inflated, scissors at bed side (Balloo n Tamponade) - effective if (-) hematemesis TIPS GASTRO ± ADULT A pt w/ appendicitis was admitted, of ALL the ff written orders, w/c shld the nu rse prioritize ± Administration of Antibiotics; w/c statement if made by a pt w/ c irrhosis is a risk factor for having the disease ± ªI drink 2 glasses of alcohol /da yº; which of the ff indicates a ruptured appendix ± absence of pain;
ff subtotal gastrectomy, the nurse shld expect gastric drainage for the 1st 12 h rs 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 yello w;
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 ± ªback arc hingº GENERAL CONSIDERATION When assessing the neurological system, pay attention to the ff:
#1 LEVEL OF CONSCIOUSNESS #2 BEHAVIOR #3 REFLEX When assessing MUSCULO SYSTEM:
#1 Range of Motion #2 Joint Stiffness #3 POSTURES PEDIATRIC CONSIDERATION a. Check for bowel and bladder funx ± indicates neurologic al maturity 15-18 months ± START BOWEL TRAINING 2 yo ± start bladder training b. Ass ess for their habits ªsecurity blanketsº ± ex. Stuff toys, mother wallet Associate mother's time w/ child act ivity (children has NO DEFINITE TIME) Ex. Your mom will be back after you have e aten 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 b anging excessive thumb sucking e. CONTUSSION ± more severe, fatal and could even lead to death CONCUSSION ± jarring of the brain, ªna-alogº w/c could lead to s/s of LOC in 24-48 hrs DECORTICATE ± abnor mal flexion which indicates damage to the cortex s/s : #1 Decrease LOC #2 wideni ng 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 GLASGOW COMA SCALE EYE OPENING (4) VERBAL RESPONSE (5) 5± 4± MOTOR (6) 6 5 4 3 2 1 ± ± ± OBEYS COMMAND LOCALI ZES PAIN WITHDRAWS FROM PAIN INAPPROPRIATE 3 - DECORTICATE RIGIDITY DECEREBRATE RIGIDITY NO RESPONSE 4 3 2 1 ± ± OPEN SPONTANEOUSLY OPENS TO VERBAL COMMAND OPEN TO PAIN 2 NO RESPONSE 1 SCORE OF 3 SCORE OF 15 Score of 8 : : : ORIENTED CONFUSED INCOMPREHENSIBLE NO RESPONSE NO response (DEAD) ± Doctor will the one to pronounce pt is awake 50-50, MONITOR T HE PT
7 and BELOW : pt is COMA CRANIAL NERVES I. OLFACTORY : SENSORY : smell Abnoxious smell Anosmia ± no smell Perfume II . III. IV. VI. OPTIC : SIGHT ± snellen's chart ± 20/20 usually by age 3-6 yo OCCULOMOTOR TROCHLEAR ABDUCENS Eye movement - 6 cardinal direction of gaze (if abnormal look for DIPLOPIA) V. TRIGEMINAL : SENSORY : responsible for FACIAL SENSATION (to check, use cotton & needle and run across t he cheek) AND MOTOR : ability of pt to chew Reflex: CORNEAL REFLEX ± (+) if both eyes can blink VII. FACIAL : SENSORY : and sense of taste @ anterior 2/3 of the tongue Facial Expression MOTOR : VIII. ACOUSTIC or VESTIBULOCOCHLEAR - Sense of hearing and balance
TEST : ROMBERG'S TEST - stand erect, close eyes, observe for balance IX. X. GLOSSOPHARYNGEAL VAGUS SENSORY MOTOR ± Posterior Taste 1/3 Of The Tongue - swallowing and gag reflex XI. XII. SPINAL ACCESSORY HYPOGLOSSAL - motor movement of shoulder muscle ± TONGUE MOVEMENT DUCHENE'S MUSCULAR DYSTROPHY (DMD) X ±linked RECESSIVE (only mother transmit to SON) (-) Father Mother (+ carrier) So n - 50% chance 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 paralysis. Prognosis : complete recovery in 3 months Treatment : sp lint and cast for 3 mos ± leads to nerve
X-linked RECESSIVE DIRORDER MP characterized by progressive muscle atrophy w/c a pparent in male at the age of 3 a) GOWER'S SIGN ± inability to stand up - use arms t o brace the body b) WADDLING GAIT - duck-like gait c) impaired mobility d) diffi culty in running and climbing COMPLICATIONs LAB DATA Nsg Dx Respiratory Paralysi s ± for young children Cardio-Resp. Arrest - for adolescent Muscle Biopsy PExam In effective Breathing Pattern Impaired Physical Mobility AIRWAY (keep TRACHEO at b edside) regeneration S/S PI TX a. b. Supportive - leg brace, crutches Refer parents to geneticist Target: Mothers or FEMALES ± bec they are the source of transmission Ex. Aunt, Female Sibling, mother s, female members of the family ± (bec transmission: X linked recessive) CEREBRAL PALSY - Permanent, Fix (non-progressive) neuromuscular disorder characterized by abnor mal muscle movement. Cause S/S Unknown Exaggerated Reflexes Protrusion of the tongue or tongue thrust ing Early pattern of hand dominance Back Arching Scissors-gait Neurological Asse ssment PExam Risk for Injury Impaired Physical Mobility SAFETY a. Leg braces Med s : Anticunvulsants, Muscle Relaxants Prepare child for SURGERY ± release of TENDO N OF ACHILLES ± to promote mobility Refer child to : PT ± for gross motor movement ± w alking OT - for fine motor ± to open a bottle of soft drinks LAB DATA Nsg Dx PI b. c. d. HYDROCEPHALUS NOT A DISEASE but a manifestation of an existing disorder Related to ARNOLD CHIARI MALFORMATION DANDY WALKER SYNDROME there is ELONGATION of the BRAIN STEM or Medulla - characterized by ATRESIA of a nd it protrudes to Foramen magnum Foramen of Luschka & Magendie SIDE NOTES: FLOW OF CSF (N amt : 100- 200 ml) ± rich in glucose
From Lateral Ventricle it goes to Foramen of Munroe then to 3rd Ventricle then t o Aqueduct of Sylvius then it moves to F. of Luschka and Magendie going to 4th V entricle then it goes back to subarachnoid spaces of brain. S/S OF HYDROCEPHALUS PROJECTILE VOMITING IRRITABILITY ENLARGED HEAD ± N Head Circumference : 33-35 cm (chest circum: 31-35 cm) SEPARATION OF SKULL BONES SEIZURES SUNKEN EYES ± Can Prog ress To Bossing Sign MACEWEN SIGN ± crack pot sound upon knocking the head CT Scan MRI PExam ± focus on head circumference (tape measure ± at bedside to measure H Cir cumference) Risk for Injury SAFETY Semi Fowler's ± to prevent increase in ICP Diuret ics Anticonvulsants Ventriculo-Peritoneal Shunt ± progressive procedures (AS CHILD AGE PROGRESSES, the surgery is revised)
LAB DATA NSG DX PI Position Meds Surgery SPINA BIFIDA TYPES ± failure of a PORTION of spinal cord to fuse SB OCULTA NO SAC W/ DIMPLE or TUFT OF HAIR W/ SAC SB CYSTICA SUB TYPES: Meningocele ± w/ sac that contains CSF and meninges; Meningomyelocele ± C SF, 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 ski n; DOUGHNUT ring SURGERY WITHIN 24-48 HRS COMPLICATION Bladder and Bowel Problem Paralysis of Lower Extremities Hydrocephalus (tape mea sure- at bed side) Post Surgery Complication INCREASE ICP ICP above 15mmhg (N 0-10) Mild elevation : 11 ± 20 Moderate : 21 - 30 Severe : 31 and above With the use of INTRAVENTRICULAR or SUBDURAL MONITORING DEVICE to monitor ICP RF Hydrocephalus Space Occupying Lessions Brain Tumor Trauma S/S 1. INITIAL: Behavioral Changes ± irritability, restlessness, decrease LOC ± drow siness or pt becomes sleepy 2. Vital Signs Changes ± widening pulse pressure DECRE ASE RR and PR INCREASE temperature 3. Vomiting 4. Monitor Abnormalities ± decortic ate, decerebrate Nsg Dx PI Risk for injury To decrease ICP Head of Bed ELEVATED Evaluate Neuro Status ± Glasg ow AIRWAY Discharge Meds Instruction Anticonvulsants, Steroids, Diuretics (mannitol ± to dec amt of cerebral edema) Seizure precaution ± DARKENED ROOM MENINGITIS Inflammation of meninges w/c could be related to the presence of bacteria esp th e H. Influenza, and Neisseria Meningitidis disorder S/S of MENINGISMUS Inflammation of meninges but WITHOUT infection Usually accompany w/ resp. INC ICP + Kernig's Sign ± pain on extension of lower extremities + Brudzinkis - flex ion of neck would lead to flexion of lower ext.
- sign of MENINGEAL IRRITATION LAB DATA Nsg Dx PI Lumbar Puncture CSF Analysis Infection Risk For Injury Safety Seizure Precaution Tx the Infection Type of Infcetion: a. Bacterial Meningitis ± respiratory of droplet precaution b. Viral Meningitis enteric precaution MEDS Antibiotics to AUDIOLOGIST For Bacterial Meningitis - may cause hearing impairment - refer REYE'S SYNDROME Non inflammatory, non recurring but TOXIC ENCEPHALOPATY and HEPATOPATHY (CNS) (LIVER) RF TRIAD S/S Presence of Viral Infection Use of Aspirin Fever Impaired Liver Funx Impaired Co nsciousness w/c could lead to convulsion I II III IV V pt becomes lethargic conf usion decorticate rigidity decerebrate rigidity seizure or coma STAGES LAB DATA Bleeding and Clotting Time Liver Biopsy Neurological Assessment Risk for Injury Altered Thought Process Altered Thermoregulation Impaired Physical Mobility Trea tment ± symptomatic ± assess neuro status Bleeding ± give Vit K AVOID ASPIRIN when the re is VIRAL INFECTION Nsg DX PI CVA/ STROKE MP Decrease Oxygen to brain cells TYPES THROMBOSIS EMBOLISM HEMORRHAGE INFARCTION
RF atherosclerosis hpn obesity smoking stress age/ gender SIGNS & SYMPTOMS: 1. D EPENDS ON THE PROGRESSION a. TIA ± brief period of neurologic dysfunction that last less than 24 hrs (betwee n 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 LOB ES · · FRONTAL ± if affected ± PERSONALITY CHANGES opening); ± BROCA'S AREA (expressive aphasia ± mouth TEMPORAL - memory disturbances ± WERNICK'S LANGUAGE AREA (choice of words, understanding - RECEPTIVE APHASIA); ·PARIETAL - DISORIENTATION ± especially SPATIAL orientation; ·OCCIPITAL - VISUAL distu rbances 3. SIGNS AND SYMPTOMS INDICATIVE OF COMPLICATIONS Hemianopsia Hemiphlegia Emotio nal Lability Aphasia loss of half of the visual field (eg. Pt consumes half of the food at plate); pa ralysis of one side of the body; ªmood swingº Expressive ± inability to find right wor ds to say (damage to Brocka's Area); - pt can say right words ± mgt: picture board a nd Receptive - inability to understand spoken words (Wernick's area) mgt: talk to pt slowly Dysphagia LAB DATA Diagnostic Test instruct the pt to swallow twice to prevent aspiration Increase Cholesterol CT Scan MRI EEG Unilateral Neglect ± inability to care half o f the body Impaired Physical Mobility Risk for Injury Nsg DX
PI Position Meds SAFETY Semi-fowler's Elevated Antihypertensive Diuretics Antilipimic Agents Antico nvulsants Thrombolytics ± if (+) thrombus ± to dissolve clots Low Na and Cholesterol Range of Motion Exercises Craniotomy Infratentorial Cranio ± FLAT Supratentorial - Semi-fowler's DIET Activity Surgery DISEASES OF NEUROMUSCULAR : Guillain Barre Syndrome (GBS) Myastenia Gravis (MG) Multiple Sclerosis (MS) Amyo trophic Lateral Sclerosis (ALS) GBS · · · Descending paralysis ± start @ upper ext. NO gender related factor but could be re lated to viral infxn Reversible MG Common in Male and Female Early onset : 20-30 yo (Female) Early onset : above 50 yo (male) Deficiency in ACTH Receptor Sites ± Or Def. in ACTH ± MP Inflammation that leads to destruction of Peripheral Nerves 90% w/c leads to: ASCENDING GBS ªneurotransmitterº DESCENDING GBS Mixed Type GBS ASCENDING GBS - #1 C lumsiness that eventually lead to face muscle weakness & resp. depression which to telebabadº) S/S Muscle weakness w/c begins at therefore, Diplopia and Ptosis ± progresses to MASK-LIKE face which lead respiratory depression (descending paral ysis ± start at face ± ªNO LAB DATA Nsg Dx PI MEDS CSF ± Increase CHON (to all neuromusco disorders) TENSILLON TEST ± 5 mins same same Neostigmine ± ATSO4 - antidote Avoid crowded areas : viral infection Ineffective Breathing Pattern (ALL) AIRWAY (tracheostomy ± bed side) ± ALL Steroids Refer to NEUROLOGIST, PULMOLOGIST and PT MYASTHENIA GRAVIS COMPLICATIONS · · Myasthenia Crisis (MC) Cholinergic Crisis (CC) - due to under medication or lack of meds; - due to over medication ± overdose
Signs and symptoms of above complication: MUSCLE WEAKNESS ± in MC due to ACTH Defi ciency while in CC due to or as adverse effect of the drug Treatment : TENSILLON ± effective in MC ± it INCREASE MUSCLE STRENGTH Effect in CC ± it worsens muscle weak ness once given ± give ATSO4 NEOSTIGMINE ± for MC as TREATMENT MULTIPLE SCLEROSIS Common among women ± especially white There is destruction of MYELIN SHEET at CNS , therefore generalized muscle weakness Eg. ªI know I will be eventually confined in the wheelchair s/s of generalized mus cle weakness: FACIAL ± diplopia Impaired Cerebellar Funx Ataxic Gait ± ªlasingº Impaired Sensation ± NO HOT/COLD BATH Impaired Sensory Funx ± impotence dyemlination LAB DATA #1 MRI ± specific test for MS ± it localizes the area of plaque formation or the are a of #2 CT SCAN NSG DX DRUGS same with GBS & MG STEROIDS Anticonvulsants ± dilantin Muscle relaxant ± Baclofen Bl adder Stimulants ± Urecholine (bethanicol) AVOID : HOT COLD SHOWER Refer to PT: RO M Exercises HX TEACHINGS AMYOTHROPIC LATERAL SCLEROSIS (LON GAHRIG'S DISEASE) MP Destruction of Upper and Lower Motor Neurons; Geneticall y Transmitted: AUTOSOMAL DOMINANT ± common in Male & Female More Pronounce is DYSP HAGIA The muscle weakness ± will eventually lead to RESPIRATORY DEPRESSION LABDATA CSF ± Increase CHON EMG ± ªcontract and relaxº ± needle insertion Muscle biopsy Ineffectiv e Breathing Pattern AIRWAY (tracheostomy) SUPPORTIVE Refer to Geneticist NSG DX PI SIDE NOTES:
DSES A Recessive : A Dominant : Cystic Fibro, Sickle Cell, Apalstic/Fanconis ± either or both parents are (+) for trait NOT Retinoblastoma, ALS ± either father or mother (+) for disease or trait X Link Recessive : Hemophilia, Color Blindness, Duchennes Muscular, G6PD Dses ± mo ther (+) trait NOT DSES and transmit to SON SPINAL CORD INJURY Destruction of S. Cord related to TRAUMA TYPES · · · · · PI CERVICAL THORACIC LUMBAR SACRAL COCCYGEAL SAFETY 8 ± most serious ± quadriphlegia 12 5 5 1 - immobilize, surgery LUMBOSACRAL AREA ± if affected, therefore PARAPHLEGIA ± bowel and bladder problem TH ORACIC CERVICAL c1 ± c4 C5 ± C8 LAB DATA Myelogram CT Scan Xray Risk for Injury Impa ired Physical Mobility SAFETY a. b. Immobilize the spine ± side lying w/ pillows bet legs Surgery - paraphlegia + bowel and bladder problem - incomplete or partial quadriphlegia - Complete quadriphlegia Nsg Dx PI COMPLICATIONS OF SPINAL INJURY : AUTONOMIC DYSREFLXIA ± due to full bladder and bo wel s/s : #1 INITIAL : HPN #2 Diaphoresis #3 slight fever what to keep at bedside: C ATHETER - 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 underst ands the procedure ± ªI will wash my hair after the procedureº;
· · · · · · A pt w/ tumor of the frontal lobe will most likely manifest ± difficulty in concen trating; A pt w/ M. Sclerosis has urinary incontinence. To achieve voiding, w/c nsg care shld the nurse give ± establishing regular voiding sked; While interviewi ng a pt. w/ Myasthenia gravis, w/c of the ff statements confirm the dx ± ªI have dif ficulty in swallowingº; 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 p t w/ C4 Spinal Injury, w/c equipment shld the nurse keep @ the b.side ± Urinary Ca theterization Set; The PRIORITY NSG DX for pt w/ Myasthenic Crisis ± Ineffective B reathing Pattern MUSCULO CLUBFOOT DEFORMITY MP Types Talipes Varus ± ªinversionº Talipes Valgus ± ªeversionº Talipes Equinus ± ªtiptoeº L TA Nsg Dx PI PE Xray Impaired Physical Mobility Promote Mobility Congenital Foot twisted out of place
#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: R EPORT Capillary refill ± if more than 3 sec. EDEMA Skin Color/ nailbed CONGENITAL HIP DISLOCATION MP S/S Maldevelopment of the Hips ± that involves the acetabulum, head of femur or both Extra Gluteal Fold ± at affected side; Ortoloni's Sign ± (+) Click Trendelenburg Sign or Pelvic Dropping ± Alli's Sign or Galleazi's Sign ± LAB DATA when child stand in one foot toward the affected side, then there is change in l ength shortening of the affected leg PExam Barlow's Manuever ± press leg downward ± (+) click Ortolani's ± abduct leg sideward ± (+) click Impaired Physical Mobility #1 Double or triple diaper ± to keep legs in abducted position; #2 PAVLIK Harness - for 2-3 mos #3 Hip Spica Cast LAST RESORT NO ADDUCTION OF LEGS! Nsg Dx PI FRACTURES MP TYPES Break in the continuity of the bone Open (compound) ± bone tears the skin ± therefore open: risk for infection CLOSE ± ski n intact · · · · · · · S/S AVULSION ± tear in the tendon COMMINUTED - fragmented COMPRESSED ± crushed IMPACTED ± driven to each other DEPRESSED ± pressed SPIRAL ± goes around the bone GREENSTICK ± in complete #1 Deformity #2 Pain #3 Edema
#4 CREPITUS ± sound created when two bone surface rob each other NSG DX PI Impaire d Physical Mobility MOBILITY ± immobilize the fx a. Splinting; b. Casting ± check fo r edema ± elevate the affected areas; - check skin color ± capillary refill time - c heck for presence of blood stained c. 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 all owed partial wt bearing and the other one is N; swing through - when both legs n eed to moved past the level of the crutches swing to ± when both legs need to be m oved AT THE LEVEL OF THE CRUTHES going upstairs ± unaffected then crutch (goodleg ± crutch ± bad) going down ± crutch the n bad leg ± then good leg SCOLIOSIS MP RF Lateral Deviation of the Spine STRUCTURAL ± non correctible FUNCTIONAL - cor rectible OUSTANDING S/S Uneven Hemline; Uneven waistline; Uneven shoulder (+) Rib Hump Pr ominent Iliac Crest Bend Over test ± instruct to touch the toes and note for rib h ump Xray Impaired Physical Mobility - child Body Image Disturbance - adolesence a. To decrease curvature ± wear BOSTON or MILWAUKEE Brace ± for 23 hrs/day except ba thing b. SURGERY ± HARRINGTON ROD - LUQUE Avoid : Bending Jumping Rope Playing Ten nis Trampoline Brisk Walking Swimming Cheer Leading LAB DATA Nsg Dx TX HX Teaching Allowed: OSTEOPOROSIS/ HUNGRY BONE
MP RF Loss of Bone Density #1 smoking AGING IMMOBILITY MENOPAUSE ± decrease Estrogen Sec ondary to Existing Condition ± as secondary Hyperparathyroidism PAIN Dowager's Hump Short Stature Progressive Decrease in Height Decrease in Calcium Bone Densinomet ry Bone Scan Xray SAFETY S/S LAB DATA Nsg Dx How? 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 - alendrona
te Fosomax ± SIT UPRIGHT AFTER ARTHRITIS RHEUMATOID Common Affected Part MP Chronic, systemic inflammation of connective tissues Synovial joints and joints of Upper extremities FEMALE Upper Extremities GOUTY MALE Lower Extremities OSTEOARTHRITIS MALE/FEMALE wt bearing joint S/S PAIN Inflammation Morning Stifness Stages of Rheumatoid A.
STAGE 1 ± no Disability STAGE 2 ± with Interference To ADL STAGE 3 - with major compromise of funx STAGE 4 - incapacitation ULNAR DRIFT LAB
DATA Nsg Dx PI Decrease HgB Increase ESR PAIN Impaired Physical Mobility Relief of Pain a. Warm Bath; b. MEDS : ASA - Antiinflammatory STREROIDS c. exercise: R OM SWAN NECK DEFORMITY GOUTY ARTHRITIS MP S/S Metabolic disorder of purine w/c leads to deposition or uric acid at join ts site: THE GREAT BIG TOE (+) PAIN ± usually aggravated by pressure (+) Inflammat ion above s/s affects the LOWER EXTREMITIES LAB DATA NSG DX PI Increase Uric Acid PAIN Impaired Physical Mobility Relief of PAIN Meds : Allupur inol, Probenecid Diet : Low Purine/ Purine Restricted: AVOID : Organ Meats SEAFO ODS Alcohol ALLOWED: Cheese (EXCEPT fermented and Aged) Increase ORAL Fluid Intake OSTEOARTHRITIS A degenerative joint disease that involves the weight bearing joints ± elbows & kn ees S/S PAIN ± NO inflammation Bouchard's Nodes (distal) Heberdene's Node (proximal) LAB DATA xRAY Nsg Dx PI PAIN Impaired Physical Mobility Weight Control Hot or Co ld Compress Health Teaching
ASA Trunk Assistive Device (cane) SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) Autoimmune multi system dses characterized by inflammation of connective tissues JOINT CARDIOVASCULAR CNS OUTSTANDING S/S LAB DATA Nsg Dx : : : (+) pain, (+) mo rning stiffness; (+) chest pain; (+) s/s of dec LOC, Irritability, Headache (also present in pt in PROCAINAMIDE TOXICITY) BUTTERFLY RASH Increase ESR PAIN Altered Tissue Perfusion Risk For Injury Symptomatic/ Supporti ve ± meaning, treat available s/s Steroids TX Drugs TRACTION PRINCIPLES T ± rapeze bar R ± equires free hanging weights A ± nalgesic C ± iculation mo nitoring T ± emperature monitoring I - nfection prevention O ± utput and input monit oring N ± utrition S ± kin Assessment TIPS FOR MUSCULO
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; pt i n russel's traction is being taken cared of by the nurse, it would be necessary fo r the nurse to intervene if ± the pt feet are pressed against the foot board; a pt is using CRUTCHES for the first time, w/c action reflects a need for further in struction ± the pt bears his/her wt with his/her axial; a pt on buck's traction of t he R femur ask the nurse how he can possibly move around. What can the nurse adv ise 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;
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 muscle spasm; - to decrease
a child has hip spica cast upon discharge, w/c statement of the father indicates further instruction ± ª I will hold on to the bar bet his legs to help move himº INTEGUMENTARY SYSTEM Burn ± triage : face and perineum (priority) BURNS Traumatic injury to the skin brought about by : FIRE CHEMICALS PROLONGED EXPOSUR E TO SUN ELECTRICAL CURRENT HOT H2O CLASSSIFICATION:
According to Damage
PARTIAL THICKNESS ± FIRST DEGREE EPIDERMIS Pain Redness Eg sunburn 2ND DEGREE EPIDERMIS & PART OF DERMIS Redness Blister Formation pain FULL THICKNESS
THIRD DEGREE SUB Q FATS MUSCLES LEATHERY APPEARANCE NO Pain 4TH DEGREE SUB Q FATS MUSCLES & BONES CHARRED APPEARANCE No Pain MINOR PARTIAL TICKNESS FULL THICKNESS less than 15% NONE MODERATE 15-25% <10% MAJOR 25% >10% RULE OF 9 ± CHECK NOTE day 9 page115 BURN TRIAGE Priority : Burns of FACE PERIMEUM UPPER & LOWER EXT Burn related to Child Abuse Chemical ± Fire THINK: R escue A larm C onfine the Fire E xtinguish the Fire PRINCIPLES OF NSG CARE FOR BURN PTS:
B ± reathing ± Airway U ± rine output monitoring R ± esuscitation of Fluids N ± utrition S ± ilvadene Ointment DIET DAT (High CHON, Ca, Vit C) FIRST 24HRS ± SHOCK 72Hrs - INFECTION Complication Pt Preparation :Bed Craddle Fever dog ticks LYME'S DISEASE Rocky Mountain caused by BORRELIA BURGDORFERI
(deer ticks) Dermacentor/ Variabilis ±
3-30 days or Dermacentor Andersori (wood) 2-3 wks s/s : Fever, Pain, Chills, Rashes Generalized rashes RASHES: Bull's Eye Rash or Rounder Rings At moist body parts Complications Cardio, Musculoskeletal and CNS - which can lead to paralysis TX PI Avoid wooded area ± ªhave you been to the woods?º Vaccination Use long sleeve Remove t icks w/ twizers ± upward straight motion Chloramphenicol Tetracycline Meds DERMATITIS DIAPER (contact) Peak patients S/S : During infancy ± 9-12 mos Due to prolonged exposure to urine, soap & excreta ATOPIC ECZEMA (adult) Cause : Hereditary Prone to asthmatic : RASH RASH + scaling, Crusting Pruritus or itching Viscicles Management: Hydrate the s kin w/ cold compress Meds: Benadryl (antihistamine) ROSEOLA Exanthem Causative Agent INC PERIOD RUBEOLA MEASLES Measle Virus 10 -20 days RUBELLA GERMAN MEASLES Rubella Virus 14 -21 days Herpez Virus Unknown s/s RASH FEVER and RASH Begins w/ face & downwards Face & downwards Non Pruritic Rose pink ± begins w/ trunk
Progressing outward With KOPLICK'S SPOTS 3 C's : Coryza Cough Conjuctivitis MANAGEMENT: (to all types) B ed rest Antibiotics Antipyretic + same SYPHYLLIS C Agent I. Period T Pallidum 10-13 wks GONORRHEA N Gonorrhea 2-7 days Zoster HERPEZ Simplex Vericella Zoster Virus Herpes Simplex Viruz Genital H Abdominal Oral Herpez Steroids 2-12 days vesicle Around the mouth Inner thigh Buttocks Genitals Acyclovir Cervical Ca ± complication of Herpez Annual pap smear TRICHOMONIASIS Caused by TRICHOMONAS Vaginalis Both are STDs Charac of discharge : Greenish/ Ye llowish With FOUL ODOR Inc Period Druf pf Choice 4 ± 20 days Flagyl MONILIASIS/CANDIDIASIS Albicans WHITISH-CHEESELIKE discharge 2 ± 5 days Amphotericin
TIPS A nurse admits 8yo brought by her mother. Upon assessment, the nurse finds round ed rings of rash. This is indicative of ± lyme's dses; During the immediate 24hrs po t burn, w/c of the ff is the priority ± administration of fluis; A pt tells the nu rse that he notice small blisters on his private parts. This is indicative of ± HE RPEZ 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 effectiv e 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 CHLAMYDI ASIS ± burning on urination
CANCER Cause RF Unknown Theory of USE - Overuse, Underuse, and Abuse Smoking : RACE : L ung, Bladder and Laryngeal or Oral CA Jewish ± Breast Blacks - Cervix and Prostrat e Whites ± Testes Nulliparity ± breast having baby after 35 yo Multiparity ± cervix Hi gh Fat and Low Fiber ± CA of Colon Spicy ± Ca of Prostrate PARITY : DIET :
Raw ± Ca of Stomach LABDATA egins age 16 yo- target are xually active) - anually b. phy ± baseline : 35-40 yo : TH MALE AND FEMALE
Screening Exams Male: a. Testicular Self Exam ± mothly ± b high school Female: a. Pap smear ± at age of 18 (if se Breast self exam ± beginning age 20 ± monthly c. Mamogra AFTER 40 yo ± once every 2years After age 50 ± annually BO
Nsg Dx
Digital Rectal Exam Sigmoidoscopy STOOL FOR OCCULT BLD : : 40 and above ± ANUALLY ANUALLY after age 50yo Annually after age 50 yo Knowledge d eficit HOPELESSNESS Initial If pt is TERMINALLY ILL If pt has some wishes or Unfulfilled needS : Powerlessness 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 COMMON S/S LARYNX LUNGS STOMACH BREAST OVARIAN CERVICAL PROSTRATE COLON Hodgkin's Dses TESTICULAR change in VOICE or Hoarseness changing cough or s moker's cough (productive) dyspepsia a lump or a discharge complains feeling of fu llness or indigestion ªbleedingº elevated acid phosphatase, nocturia change in bowel habits painless enlargement of lymph nodes crytorchidism, spongy testes or lump (N ± smooth unequal) TIPS FOR CANCER 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 ; w/c of the ff is an appropriate diet for pt undergoing chemo ± bland diet; the m ost common sign of Breast Ca is in ± upper outer quadrant; pt w/ CA of esophagus w ill manifest ± DYSPHAGIA
TIPS FOR
PSYCHE A pt w/ chronic depression is to undergo ECT, the purpose is to ± relieve the symp toms of depression; A nurse shld assess the pt w/ ALZEIMER'S DSES for possible cha nge in ± orientation; A pt w/ bipolar episodes is ready for discharge when ± she can comply with units activities; The nurse would suspect that the child is a victi m of abuse if he ± keeps quiet while an IV is inserted; w/c of the ff situations r eflects an increase in self-esteem 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 wo uld require the pt to ± remain in public place 1 hour after meals; where shld the nurse put the pt on early alcoholic withdrawal ± well-lighted room near nurses sta tion
TIPS FOR OB-GYNE
A Mother Is Crying Besides her baby, she said ªI feel so sorry I couldn't hold herº ± le t her stroke the baby; 6wks pregnant woman ask the nurse about the signs of preg nancy ± w/c one is expected at this time ± frequent urination; the nurse notes mirro r image in the fetal monitor ± this could be related to FETAL HEAD COMPRESSION; wh ich 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 duratio n of contraction ± she is correct when she times it from the beginning of one cont raction to the end of same contraction TIPS PEDIA w/c of the ff is expected by 6mos of age ± sits w/ minimal support; the most appro priate toy for 18 mos old child ± carriage w/ a doll; the appropriate room mate fo r 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 word s used for objects and routines;
w/c of the ff is appropriate way of administering pre-op meds to 4 yo child ± ask the child where she would like the injecvtion to be given
Paralysis of Lower
