Compilation of Review from: 1. R.A. Gapuz Review Center 2. Royal Pentagon Review Center 3. Merge Review Center 4. KAPLAN 5. Edgeworth 6. Scribd 7. Nursing crib
Prayer for Students God of Light and Truth, thank you for giving me a mind that can know and a heart that can love. Help me to keep learning every ev ery day of my life, lif e, for all knowledge leads to you. Let me be aware of your presence in all things and at al l times. Encourage me when work is difficult and when I am tempted to give up; encourage me wh en my brain seems slow and the way forward f orward is difficult. Grant me the grace to put my mind to use exploring the world you have created, confident that in you there a wisdom that is real. Amen. Charles Henderson
Prayer to St. Joseph of Cupertino for success in Examinations. This powerful prayer is very effective in examinations. It has to be said before appearing in the examination. There There are two variants v ariants to this prayer. Both the prayers are equally effective. You can choose any one of these:First Prayer O Great St. Joseph of Cupertino who while on earth did obtain from God the grace to be asked at your examination only the questions you knew, obtain for me a like favor in the examinations for which I am now preparing. In return I p romise to make you known and cause you to be invoked. Through Christ our Lord. St. Joseph of Cupertino, Pray for us. Amen.
Second Prayer O St. Joseph of Cupertino who by your prayer obtained from God to be asked at your examination, the only preposition you knew. Grant that I may like y ou succeed in the (here mention the name of Examination eg. History paper I ) examination. In return I promise to make you known and cause you to be invoked. O St. Joseph of Cupertino pray for me O Holy Ghost enlighten me Our Lady of Good Studies pray for me Sacred Head of Jesus, Seat of divine wisdom, enlighten me.
Remember, when you succeed in the exams then you should thank St. Joseph of Cupertino in the Newspaper.
1. Fundamental of Nursing 2. Leadership and Nursing Management 3. Nursing Research 4. Professional Adjustment
Types
of Leadership:
AUTHORITARIAN OR AUTHOCRATIC leaders makes own decision..More concerned concerned task accomplishment accomplishment than w/ concern for people. It promotes hostility and aggression or apathy to decrease initiative. DEMOCRATIC PARTICIPATIVE- leaders involved their follower in decision making process. People oriented focusing on human relations en team work. lead to increased productivity and job satisfaction. LAISSEZ-FAIRE OR PERMISSIVE- leaders are loose and permissive and abstain from leading their staff. They foster freedom for everyone en wants ev eryone to feed good. Leadership results in low productivity en employees Frustrations Pattern of Nursing Care: Case Method/Total Patient Care In case method, the nurse cares for one patient whom the n urse cares for exclusively. The Case Method evolved into what we now call private duty nursing. It was the first type of nursing care delivery system. In Total Patient Care, the nurse is responsible for t he total care of the patient during the nurses working shift. The RN is responsible for several patients. Functional Nursing It is a task-oriented method wherein a particular nursing function is assigned to each staff member. The medication nurse, treatment nurse and bedside nurse are all products of this system. For efficiency, nursing was essentially divided into tasks, a model that proved very beneficial when staffing was poor. The key idea was for nurses to be assigned to tasks, not to patients. Team
Nursing The goal of team nursing is for a team to work democratically. Primary Nursing The hallmark of this modality is that one nurse cares for one group of patients with 24-hour accountability accounta bility for planning their care. Modular Nursing (District Nursing) This is a modification of team and primary nursing. I t is a geographical assignment of patient that encourages continuity continuity of care by organizing o rganizing a group of staff to work with a group of patients in the same locale. l ocale.
Expanded Nursing Role: 1. Nurse Practitioner Pra ctitioner A nurse who has an advanced education and is a graduate of a nurse practitioner program. These nurses are in areas as adult nurse practitioner, family nurse practitioner, school nurse practitioner, pediatric nurse practitioner, or gerontology nurse practitioner. 2. Clinical Nurse Specialist A nurse who has an advanced degree or expertise and is considered to be an expert in a specialized area of practice (e.g., gerontology, g erontology, oncology). 3. Nurse Anesthetist A nurse who has completed advanced education in an accredited program in anesthesiology. The nurse anesthetist carries out pre-operative visits and assessments, and Administers general anesthetics for surgery under the supervision of a physician prepared in anesthesiology. The nurse anesthetist also assesses the postoperative postoperative of clients c lients 4. Nurse Midwife A RN who has completed a program in midwifery. 5. Nurse Educator Nurse educator is employed in nursing programs, at educational institutions, and in hospital staff education e ducation.. 6. Nurse Entrepreneur A nurse who usually has an advanced degree and manages a health-related business. The nurse may be involved in education, consultation, or research.
Level of Prevention by Leavell and Clark: Primary Prevention Providing specific protection against disease to prevent its occurrence is the most desirable form of prevention. Examples: a. Mandatory immunization of children belonging to the age range of 0 59 months old to control acute infection diseases. b. Minimizing contamination of the work or general environment by asbestos dust, silicone dust, smoke, chemical pollutants and excessive noise. Secondary Prevention Early diagnosis of a health problem can decrease the catastrophic effects that might otherwise result for the individual and the family f rom advanced illness and its many complications. Examples:
a. Public education to promote breast self-examination, use of home kits for detection of occult blood in stool specimens and familiarity with the seven cancer danger signals. b. Screening programs for hypertension, diabetes. Uterine cancer(pap smear), breast cancer (examination and mammograph mammography), y), glaucoma and an d sexually transmitted disease. Tertiary Prevention Continuing health supervision during rehabilitation to restore an individual to an optimal level of functioning.
Three way bottle: st
1 drainage system shows a simple drainage system that can be connected to suction or to a Heimlich valve. The fluid-collection bottle would have measurement markings on it to help clinicians track the amount of fluid collected. This system could allow for reduction of a pneumothorax
2
nd
water seal and drainage bottle
shows the addition of a water-sealed bottle to the s imple drainage system. This helps to stop the problem of air m oving back into the chest, and it also provides greater capacity for the collection of blood or body f luids without any clogging of the suction outlet/connection.
rd
3 drainage, water seal, and suction The system has a fluid-collection bottle and a water-sealed bottle, along with a pressure-regulating bottle. This bottle helps the system maintain a measured, constant negative pressure and negative flow.
Bubbling: *Bubbles in suction: Continues *Bubbles in water seal: Intermittent I ntermittent *What if there is continues bubbling in water seal due to air leak? We need to clamp immediately the tube near the client *What if there is no bubble? No bubbles means normal or there is an obstruction *How to remove obstruction? By press release maneuvers *The tube disconnects? Disconnect Disconnect in the site ( cover the hole w/ vassoclussive dressing) Disconnect in the whole bottle (reconnect the tube) *If broken bottle? Immerse in new bottle *If the tube disconnect? -Clamp -Notify Physician -Immerse in new bottle -Reconnect the tube *Clamp is only for leakage Care for Tracheostomy and function of Cuff, obturator, and Tie 1. Explain procedure to patient. 2. If tracheostomy tube has been suctioned, remove soiled dressing from around tube and discard with gloves on removal. 3. Perform hand hygiene and open necessary supplies. Cleaning A Nondisposable Inner Cannula 1. Prepare supplies before cleaning inner cannula.
1. 2. 3. 4. 1.
a. Open tracheostomy care kit and separate basins, touching touching only the edges. If kit is not available, open two sterile basins. b. Fill one basin fraction ½-inch (1.25 cm) deep with hydrogen peroxide. c. Fill other basin fraction ½-inch (1.25 cm) deep with saline. d. Open sterile brush or pipe cleaners if they are not already in cleaning kit. Open additional sterile gauze pad. Don disposable gloves. Remove oxygen source if one is present. Rotate lo ck on inner cannula in a counterclockwise motion to release it. Gently remove inner cannula and carefully drop it in basin with hydrogen peroxide. Remove gloves and discard. Clean inner cannula. a. Don sterile gloves. b. Remove inner cannula from soaking solution. Moisten brush or pipe cleaners in saline and insert into tube, using back-and-forth motion. c. Agitate cannula in saline solution. Remove and tap against inner surface of basin.
d. Place on sterile gauze pad. 1. Suction outer cannula using sterile technique. 2. Replace inner cannula into outer cannula. Turn lock clockwise and make sure that inner cannula cannul a is secure. Reapply oxygen source if needed. Replacing Disposable Inner Cannula 1. Release lock. Gently remove inner cannula and place in disposable bag. Discard gloves and don sterile ones to insert new cannula. Replace with appropriately sized new cannula. Engage lock on inner cannula. Applying Clean Dressing and Tape 1. Dip cotton-tipped applicator in saline and clean st oma under faceplate. Use each applicator only once, moving from stoma site outward. 2. Apply hydrogen peroxide to area around stoma, faceplate, and outer cannula if secretions se cretions prove difficult to remove. Rinse area with saline. 3. Pat skin gently with dry 4 x 4 gauze. 4. Slide commercially prepared tracheostomy dressing or prefolded non-cotton-filled 4 x 4dressing under faceplate. Tie
a. Leave soiled tape in place until new one is applied. b. Cut piece of tape that is twice the neck circumference c ircumference plus 4 inches (10 cm). Trim ends on the diagonal. c. Insert one end of tape through faceplate opening alongside old tape. Pull through until both ends are even. d. Slide both tapes under patients neck and insert one end through remaining opening on other side of faceplate. Pull snugly and tie ends in double square knot. Check that patient can flex neck comfortably. e. Carefully remove old tape. Reapply oxygen source if necessary. 1. Remove gloves and discard. Perform hand hygien e. Assess patients respirations. Document assessments and completion of procedure. Obturator
The obturator is used only to guide the outer tube during insertion and is removed immediately after the outer tube is in place. Cuff A tracheostomy cuff is a balloon around the outside of the trach tube. When the balloon is filled with air it fits the shape of your windpipe. The balloon seals off the space between the wall of your windpipe and the trach tube. This seal is needed when you are on a breathing machine (ventilator) or if you have problems with choking. If the cuff is not inflated, air can pass around the trach tube.
Postural Drainage *POPEVICO [arrangement] [arrangement] that is positioning, percussing, vibrating and coughing *Do this before meals, the positioning depending on the location of secretion Different position:
Suction To assist in the removal of bronchial secretions that cannot be expectorated by by the patient spontaneously. * INDICATIONS: 1. Visible presence of secretions in tube orifice 2. Coarse tubular breath sounds on auscultation in patient unable to cough or without artificial airway in place. 3. Patient with an artificial airway. *Once catheter has been placed in i n trachea, slowly withdraw while applying intermittent suction and rotating catheter. Remember: Suction should should not be applied f or more than 10-15 seconds. *Precautions/Complications, 1. Hypoxia 2. Vagal stimulation: Cardiac arrhythmia 3. Tracheitis Independent and dependent variable Independent variable
-use this to stimulate a target population/cause Dependent variable/Effectual variable -results of the effects of the study Examples A comparative Study in the Income of Filipino Nurses Employed in P.G.H. and N.Y.G.H. Independent variable: PGH and NYGH (place of work) Target population: Filipino nurses Dependent variable: income
PURE and APPLIED as well as EXPERIMENTAL and NON-EXPERIMENTAL also your QUANTITATIVE and QUALITATIVE designs Basic/pure
research -only the research benefits the research -It is only for your y our personal necessity -Answers your own question Applied research -problem solving -Solving the problems of the patient.
Experimental Performing active manipulation, observe and record the result. Types of Experimental Research
Control Divide group into 2. -Group a control/comparison grp will use the s ame soap everyday -Group b experimental grp those who wi ll use the sample soap Randomization
-using sample by chance. -Choose randomly to avoid redundancy of result Manipulation -Performing intervention Validation
-comparison of the effects Quasi-experimental -false experiment. -No control sample. Non-experimental No manipulation is done. Only observation, describe and record down the result. Types of non-experimental research design Retrospective (Ex Post Facto)
-Getting actual experience
base on time element
-Studies a group of people after its occurrence, occurrence, experience or facts. -Experience of people in the past Descriptive -Observe, describe & record. -Study of current events. Prospective -Study of research about future occurrence or future events. Historical
-Past that is written, documented, published and recorded Primary Data -Observe st -1 hand information -person himself Secondary Data nd -2 Hand Information -About the past using records, journals, books. -Study of the dead people thru his written materials, facts Quantitative -data base on numerical interpretation, datas that are measurable, using your senses, se nses, data that are observable. Qualitative -subjective data, feelings, perception, beliefs, c ulture, attitude Intra Venous Fluid Tonicty
Isotonic
D5W NS D5 0.5 NaCl D5 1/4 NS LR
Hypertonic D10W D5NS D5 0.5 NS
Hypotonic 0.45NS ½ NS
Complication of IVF: 1. Infiltration nfiltration the needle is out of vein, and f luids accumulate in the subcutaneous tissues. Assessment: - Pain, swelling, skin is cold at nee dle site; pallor of the site, flow rate has decreases or stops.
Nursing Intervention: - Change the site of needle - Apply warm compress. This will absorb edema fluids and reduce swelling. 2. Circulatory Overload - Results from administration of excessive volume of IV fluids. Assessment: - Headache - Flushed skin - Rapid pulse - Increase BP - Weight gain - Syncope and faintness - Pulmonary edema - Increase volume pressure - SOB - Coughing - Tachypnea - Shock Nursing Interventions: - Slow infusion to KVO - Place patient in high fowlers position. To enhance breathing - Administer diuretic, bronchodilator as ordered 3. Superficial Thrombophlebitis hrombophlebitis it is due to overuse of a vein, irritating solution or drugs, clot formation, large bore catheters. Assessment: -Pain along the course of vein -Vein may feel hard and cordlike -Edema and redness at needle insertion site. -Arm feels warmer than the other arm Nursing Intervention: -Change IV site every 72 hours -Use large veins for irritating fluids. - Stabilize venipuncture at area of flexion. -Apply cold compress immediately to relieve pain and i nflammation; later with warm compress to stimulate circulation and promotion absorption. -Do not irrigate the IV because this could push cl ot into the systemic circulation
4. Air Embolism Embolism Air manages to get into the circulatory system; 5 ml of air or more causes air embolism. Assessment: -Chest, shoulder, or backpain -Hypotension -Dyspnea - Cyanosis -Tachycardia -Increase venous pressure -Loss of consciousness Nursing Intervention - Do not allow IV bottle to run dry -Prime IV tubing before starting infusion. -Turn patient to left side in the trendelenburg tre ndelenburg position. To allow air to rise in the right side of the heart. This prevent pulmonary embolism. e mbolism. BLOOD TRANSFUS ION THERAPY
Objectives:
1. To increase circulating blood volume after surgery, trauma, or hemorrhage 2. To increase the number of RBCs and to maintain hemoglobin levels i n clients with severe anemia 3. To provide selected cellular components as replacements therapy (e.g clotting factors, platelets, albumin) Nursing Interventions: a. Verify doctors order. Inform the client and explain the purpose of the procedure. b. Check for cross matching and typing. To ensure compatibility c. Obtain and record baseline vital signs d. Practice strict Asepsis e. At least 2 licensed nurse check the label of the blood transfusion Check the following: -Serial number -Blood component -Blood type -Rh factor -Expiration date -Screening test (VDRL, HBsAg, malarial smear)
- this is to ensure that the blood is free from blood-carried diseases and therefore, safe from transfusion. f. Warm blood at room temperature before transfusion to prevent chills. g. Identify client properly. Two Nurses check the clients identification. h. Use needle gauge 18 to 19. This allows easy flow of blood. j.Use BT set with special micron mesh filter. To prevent administration of blood clots and particles. k. Start infusion slowly slowly at 10 gtts/min. Remain at bedside for 15 to 30 minutes. Adverse reaction usually occurs during the first 15 to 20 mi nutes. l. Monitor vital signs. Altered vital signs indicate adverse reaction. Do not mixed medications with blood transfusion. To prevent adverse effects - Do not incorporate medication into the blood transfusion - Do not use blood transfusion line for IV push of medication. m. Administer 0.9% NaCl before, during or after BT. Never administer IV fluids with dextrose. Dextrose causes hemolysis. n. Administer BT for 4 hours (whole blood, packed rbc). For plasma, platelets, cryoprecipitate, transfuse quickly (20 minutes) clotting factor can easily be destroyed. Complications of Blood Transfusion 1. Allergic Reaction eaction it is caused by sensitivity to plasma protein of donor antibody, which reacts with recipient antigen. Assessments -Flushing -Rush, hives -Pruritus -Laryngeal edema, difficulty of breathing emolytic it is caused by hypersensitivity to donor white cells, 2. Febrile, Non- Hemolytic platelets or plasma proteins. This is the most symptomatic complication of blood transfusion Assessments: -Sudden chills and fever -Flushing
-Headache -Anxiety eaction it is caused by the transfusion of blood or components 3. Septic Reaction contaminated contaminated with bacteria. Assessment: -Rapid onset of chills -Vomiting -Marked Hypotension -High fever 4. Circulatory Overload it is caused by administration of blood volume at a rate greater than the circulatory system s ystem can accommodate. Assessment -Rise in venous pressure -Dyspnea -Crackles or rales -Distended neck vein -Cough -Elevated BP 5. Hemolytic reaction. reaction . It is caused by infusion of incompatible blood products. Assessment -Low back pain (first sign). This is due to inflammatory response of the kidneys to incompatible blood. -Chills -Feeling of fullness -Tachycardia -Flushing -Tachypnea -Hypotension -Bleeding -Vascular collapse -Acute renal failure Nursing Interventions when complications occurs in Blood transfusion 1. If blood transfusion t ransfusion reaction occurs. STOP THE TRANSFUSION. 2. Start IV line (0.9% Na Cl) 3. Place the client in fowlers position if with SOB and administer O2 therapy. 4. The nurse remains with the client, observing signs and symptoms and monitoring vital signs as often as every 5 minutes. 5. Notify the physician immediately. 6. The nurse prepares to administer emergency drugs such as antihistamines, antihistamines, vasopressor, fluids, and steroids as per physicians order or protocol.
7. Obtain a urine specimen and send to the laboratory to determine p resence of hemoglobin as a result of RBC hemolysis. 8. Blood container, tubing, attached label, and transfusion record are saved and returned to t o the laboratory for analysis. *SAFETY: Causes of injuries according to age eg: elderly = falls, infant = suffocation and aspiration, adolescence adolescence = suicide and homicide. Intervention I ntervention in an elderly client who falls frequently = keep the bed at the lowest possible position. etc. Board
of Nursing
Code of Ethics BON Resolution 220 Created by: BON Helped by: PNA Law making power: Quasilegistative power- Power of BON to formulate f ormulate law When: 1982 Violates the code of ethics: Punishment/ Remove or Suspension of the nursing license Name of power: Quasi Judicial Power Who revokes license: BON Pattern use for power: Code of good governance Purpose of code of ethics: Establish ethical standard of care
1. Maternal Health Nursing 2. Child Health Nursing 3. Community Health Nursing 4. IMCI 5. Copar
Stages of Labor Stage 1 (From true labor to complete cervical Dilation) Significance Physiologic changes Maternal attitude
Nursing Intervention
Latent 0-3cm cervical dilation Excited and Happy
Active 4-7cm cervical dilation Difficulty of following instruction
Inform the labor progress
Encourage and praise client
Transitional 8-10cm cervical dilation Irritable and restlessness; Circuoral pale
Stage 2 (Complete dilation to birth of baby) *Complete Cervical Dilation *Mother needs Increase Involvement in labor *Nursing Intervention: Initiates and maintain airway of neonates Stage 3 (from birth to placental delivery) *Uterine shape change *Mother Attitude is cooperative *Nursing Intervention: Ensure complete placental delivery Stage 4 (From complete Placental delivery to two four hours after delivery) *Fundus is firm *Mother attitude is Excited and fatigue * Nursing Intervention: Monitor for sign of infection Menstrual Cycle 1 ± 5 days ± menses 6 ± 14 ± proliferative= Increase estrogen 15 ± 22 ± secretory= Increase Progesterone th 23 ± 28 ± ischemic = 24 day Corpus Albicans (whitish) corpus luteum degenerates and th becomes white. 28 day if no sperm united the ovum, the uterine begins to slough off to have the next menstruation.
Causes of Bleeding during Pregnancy First Trimester Bleeding Abortion termination of labor before age of viability v iability SP ONTANEOUS o o
AKA miscarriage Causes
1. Chromosomal Chromosomal aberrations due to advanced maternal age 2. Blighted ovum 3. germ plasm defect o Natures way of expelling defective babies Classifications : o 1. Threatened y Pregnancy is jeopardized by bleeding and cramping but the cervix is closed and can be saved. 2. Inevitable y Moderate bleeding, cramping, tissue protrudes from the cervix and the cervix is open. Types : o 1. Complete y All products of conception are expelled. y Mgt : emotional support 2. Incomplete y placenta and membranes retained. y Mgt : D&C HABITUAL o 3 or more consecutive pregnancies result in abortion usually related to incompetent incompetent cervix. Management (suture of cervix) o 1. McDonald procedure y Temporary circlage y Side effect infection y May have NSD 2. Shirodkar y CS delivery MISSED o fetus dies; product of conception remain in uterus 4 weeks or longer o signs of pregnancy cease 1. (-) pregnancy test 2. Dark brown 3. Scanty bleeding o Mgt : induction of labor/ vacuum extraction
INDUCED o
Therapeutic abortion principle of 2 fold effect 1. Done when mother has class 4 heart disease
Ectopic Pregnancy
y occurs when gestation is location outside the uterine cavity y Common site : Ampulla or Tubal y Dangerous site: Interstitial Unruptured
y Missed period y Abdominal Abdominal pain within w ithin 3- 5wks of y y
missed period (maybe generalized of one sided) Scant, dark brown vaginal bleeding Vague discomfort
Ruptured
y sudden, sharp severe unilateral pain, knife like y shoulder pain (indicative of intraperitoneal intraperitoneal bleeding that extends to diaphragm & phrenic nerve) y (+) Cullens sign bluish tinged umbilicus y syncope/fainting
y Nursing Care : vital signs o administer IV fluids o monitor for vaginal bleeding o monitor I&O o prepare for culdocentesis to determine o hemoperitoneum Mgt : non-surgical Methotrexate o
y
SECOND
TRIMESTER BLEEDING Hydatidiform Mole / bunch of grapes y Gestational Trophoblastic Disease progressive degeneration of Chorionic Villi y gestational anomaly of the placenta consisting of a bunch of clear vesicles. This neoplasm is formed from the swelling of the chronic villi and lost nucleus of the fertilized egg. The nucleus of the sperm duplicates, producing a diploid number 46xx. It grows and enlarges the uterus very rapidly. y Cause : Unknown y Assessment : o Early signs vesicles passed thru the vagina Hyperemesis gravidarum due to HCG Fundal height Vaginal bleeding (scant or profuse) Early in pregnancy o high levels of HCG Pre ecclampsia at about 12wks
y
Vesicles look like a snowstorm on sonogram Anemia Abdominal cramping Abdominal Serious late complications o Hyperthyroidism Pulmonary embolus Nursing care : o prepare for D&C o do not give oxytocin drugs due to proneness to embolism o Health Teaching: return for pelvic exams as scheduled for one year to monitor HCG and assess for enlarged uterus and rising titer could be indicative of choriocarcinoma Avoid pregnancy for at least one year Methotrexate therapy
Incompetent Cervix Management:
y McDonald procedure Temporary circlage of incompetent cervix. o Delivery : NSVD o SE: infection o Health teaching observe for signs of infection signs of labor Shhirodkar procedure o Permanent procedure. o Delivery: caesarian section required. o
y
THIRD TRIMESTER BLEEDING
PLACENTAL ANOMALIES
Placenta Previa y it occurs when the placenta is improperly implanted in the l ower uterine segment, sometime covering the cervical os. y Assessment o Outstanding Outstanding sign : frank, bright red, painless bleeding o enlargement (usually has not occurred) o fetal distress o abnormal presentation y Nursing care : o Initial mgt : NPO candidate for CS o Bedrest o prepare to induce labor if cervix is ripe
o o o
administer IV No IE, No Sex, No enema complication : Sudden fetal blood loss prepare Mother for double set up DR is converted to OR
Abruptio Placenta
y it is the premature separation of the placenta from the implantation site. y It usually occurs after the twentieth week of pregnancy y Cause: Cocaine user o Severe PIH o Accident y Assessment: o Outstanding Outstanding sign : dark red & painful bleeding o concealed hemorrhage (retroplacental) o couvelaire uterus (caused by bleeding into the myometrium) (-) contraction o rigid boardlike abdomen o severe abdominal pain o dropping coagulation factor (a potential for DIC) o sx : bleeding to any part of the body. Mgt : for hysterectomy y General Nursing care : o infuse IV, prepare to administer blood y type and crossmatch o monitor FHR o insert Foley catheter o measure blood loss; count pads o report s/s of DIC o monitor v/s for shock o strict I&O Placental Succenturiata 1 or 2 lobes connected to the placenta by a blood vessel o
Placenta Bipartita ± placenta divided into 2 lobes Endometriosis and Endometritis: Endometriosis is a benign condition in which endometrial glands and stroma are present outside the uterine cavity and walls. The typical patient with endometriosis is in her 30s, nulliparous, and infertile. Symptoms: The characteristic triad of symptoms associated with endometriosis is dysmenorrheal, dyspareunia, and Dyschezia.
DIFFERENTIAL DIAGNOSIS (1) Chronic pelvic inflammatory disease or recurrent acute salpingitis (2) Hemorrhagic corpus luteum, (3) Benign or malignant ovarian neoplasm, and, occasionally, (4) Ectopic pregnancy. Management Total abdominal hysterectomy, bilateral salpingo-oophorectomy salpingo-oophorectomy with destruction of all peritoneal implants, and dissection of all adhesions. IMCI (Integrated Mother and Childhood Illnesses)
Danger Sign Convulsion Lethargy Inability to feed or drink Vomiting Pneumonia
If the child is: Fast breathing is: 2 months up to 12 months = 50 breaths per minute or more 12 months up to 5 years= 40 breaths per minute or more
Any general danger sign or Chest indrawing or Stridor in calm child
Fast breathing.
No signs of pneumonia or very severe disease.
SEVERE PNEUMONIA OR VERY SEVERE DISEASE PNEUMONIA
NO PNEUMONIA: COUGH OR COLD
-Give first dose of an appropriate antibiotic. -Refer URGENTLY to hospital.
-Give an appropriate antibiotic for 5 days. -Soothe the throat and relieve the c ough with a safe remedy. -Advise mother when to return immediately. -Follow-up in 2 days. -If coughing more than 30 days, r efer for assessment. -Soothe the throat and relieve the c ough with a safe remedy. -Advise mother when to return immediately. -Follow-up in 5 days if not improving.
Diarrhea Two of the following signs: Lethargic or unconscious Sunken eyes Not able to drink or drinking poorly Skin pinch goes back very slowly.
SEVERE DEHYDRATION
-if child has no other severe classification: -Give fluid for severe dehydration (Plan C). OR If child also has another severe classification: - Refer UR G ENTLY to hospital with mother giving frequent sips of ORS on the way. Advise the mother to continue breastfeeding. -If child is 2 years or older and there is cholera in your area, give antibiotic for cholera.
Two of the following signs: Restless, irritable Sunken eyes Drinks eagerly, thirsty Skin pinch goes back slowly
SOME DEHYDRATION
Not enough signs to classify as some or severe dehydration.
NO DEHYDRATION
Dehydration present.
Blood in the stool.
No dehydration.
SEVERE PERSISTENT DIARRHOEA DYSENTERY
PERSISTENT DIARRHOEA
- Give fluid and food for s ome dehydration (Plan B). - If child also has a severe classification: - Refer UR G ENTLY to hospital with mother giving frequent sips of ORS on the way. Advise the mother to continue breastfeeding. - Advise mother when to re turn immediately. - Follow-up in 5 days if n ot improving. -Give fluid and food to treat diarrhoea at home (Plan A). - Advise mother when to re turn immediately. - Follow-up in 5 days if n ot improving
- Treat dehydration before referral unless t he child has another severe classification. -Refer to hospital. -Treat for 5 days with an oral antibiotic recommended for Shigella in your area. -Follow-up in 2 days. -Advise the mother on feeding a child who has PERSISTENT DIARRHOEA. -Follow-up in 5 days.
Dengue
Any general danger sign or Stiff neck.
VERY SEVERE FEBRILE DISEASE
NO runny nose and NO measles and NO other cause of fever.
Dengue
Runny nose PRESENT or Measles PRESENT or Other cause of fever PRESENT.
FEVER DENGUE UNLIKELY
Community Health Nursing Process Assessment -Initiate Contact*Demonstrate Contact*Demonstrate -Caring attitude*Mutual trust and confidence -Collect data from all possible sources
-Give quinine for severe malaria (first dose) unless no malaria risk. -Give first dose of an appropriate antibiotic. -Treat the child to prevent low blood sugar. paracetamoll in clinic for -Give one dose of paracetamo high fever (38.5°C or above). - Refer URG ENTLY to hospital - If NO cough with fast breathing, treat with oral antimalarial. OR If cough with fast breathing, treat with cotrimoxazole for 5 days. paracetamol in clinic for -Give one dose of paracetamol high fever (38.5°C or above). -Advise mother when to return immediately. -Follow-up in 2 days if fever persists. -If fever is present every day for more than 7 days, refer for assessment. -Give one dose of paracetamol paracetamol in clinic for high fever (38.5°C or above). - Advise mother when to re turn immediately. - Follow-up in 2 days if fever persists. - If fever is present every day for more than 7 days, refer for assessment.
-Identify Health problem*Assess coping -Ability Analyze and interpret data Planning Nursing Action -Prioritize needs -Establish goal based on needs and capabilities of staff -Construction -Construction and operation plan -Develop Evaluation parameters -Revised plan as needed Implementation of planned care
-Put nursing plan into action -Coordinates care and services -Utilizes community resources -Delegate -Supervise/monitor Health Service provided -Provide health education and training -Document responses to nursing action Evaluation of care and services rendered -Nursing audit -Care outcomes -Performances appraisal -Estimate cost benefit ratio -assessment problems -Identify needed alteration -Revise plan as necessary
Type
of Budgets
Personnel -Compensation -Compensation for salaries s alaries of workers Operational
-everyday use of equipment and facilities (gloves, water, electricity) Capital -long term use equipment (MRI, CT Scan, hospital beds, hospital buildings)
Characteristics of Toddlers and pre-school Toddlers-
P RAISE
P-PushP-Push- pulls toys R- Routine and rituals A- Autonomy VS. Shame and doubt I- Involve Parents S- Separation anxiety 3 stages of separation anxiety 1. Protest (crying inconsolably) 2. Despair (Very Quiet) 3. Denial or Detachment E- Elimination (18-24 months) Sign of toilet training Dry upon waking up from a nap for 2hrs Recognize an urgent to void or defecate Ability to walk or remove clothing Yes to parents- Express there willingness for toilet training Bowel control age of 3 years old Bladder and bowel control day time age of 4 years old Bladder and bowel control night time age of 5 ye ars old Asking a 300-400 question a day Negativistic always say NO- minimize asking a question Pre-school- MAG IC M- Mutilation or fear of body injury A- Associative play or g roup play without real organization G- Guilt conscience development I- Imaginative or imaginary friend C- Curious- Concise, short, and complete Lead Poisoning ( Thesilence menace) -Plumbism Factors that contribute: 1. Pica eater and expose to hazard 2. Object that contain high amount of lead 3. Old houses build in 1950s Effect of lead 1. Blood-Anemia 2. Brain- increase ICP
3. Bone- Fracture will occur Assessment Neurologic status A. Seizure B. Irritability C. Decrease level of consciousness c onsciousness Drignulocytosis Diagnostic: -Blood lead level 10mg/dl (+) 50mg/dl (acute) 70mg/dl (severe) -X-ray lead line Therapeutic management Chelating agent 1. CaNa EDTA 2. Demerol (BAL)- Assist allergy to iodine and peanut 3. Succimer (Chenet) -Rotating injection site -Nephrotoxicity -BUN/Creatinine -Increase fluid intake Leukemia, Anemia, and sickle cell anemia, chemotherapy for pediatric Leukemia LEUKEMIA the most frequent type of childhood cancer nd Brain tumors 2 Etiology: 1. Environmental Viruses Familial/genetic Host factors STAGES OF TREATMENT INDUCTION Goal: to remove bulk of tumor Methods: surgery, radiotherapy, radiotherapy, chemotherapy, BM transplant transplant Effects: often the most intensive phase Side effects are potentially life threatening
CONSOLIDATION Goal: to eliminated any remaining malignant cells Methods: chemo/radio Side effects will still be evident MAINTENANCE Goal: to keep the the child disease free Chemotherapy This phase may last several years OBSERVATION Goal: to monitor the child at intervals for evidence of recurrent disease and complications complications of treatment Method: treatment is complete Child may continue in this stage indefinitely LATE EFFECTS OF TREATMENT Impaired growth and development deve lopment CNS damage Impaired pubertal development Development of secondary malignancy Psychologic problems related to living with a life t hreatening disease and complex treatment regimen NURSING INTERVEN I NTERVENTION TION Help child cope with intrusive procedures Provide information geared to developmental level and emotional readiness Explain what is going to happen, why it is necessary, how it will feel Allow child to handle and manipulate equipments Allow child some control in situations - Positioning, selecting injection site Support child and parents Maintain frequent clinical conferences to keep all informed Always tell the truth Acknowledge Acknowledge feelings and encourage child/family to express them Provide contact with another parent or support g roup Minimize side effects of treatment Skin breakdown Keep clean and dry; wash with warm water; no soaps or creams Do not wash off radiation marks Avoid all topical agents with alcohol Do not use heating pads or hot water bottle
Bone marrow suppression Provide frequent rest periods Avoid crowds Evaluate any potential site of infection Monitor temperature Avoid use of aspirin Select activities that are physically safe Nausea and vomiting Administer antiemetic at least half an hour before chemotherapy Eat light meal prior to administration of therapy Administer IVF if needed Alopecia Reduce trauma of hair loss Buy wig before hair falls out Discuss various head coverings Avoid exposing head to sunlight Nutrition deficits Establish baseline Provide high calorie, high protein 5. Developmental delay Facilitate return to school as soon as possible Discuss limit setting, discipline LEUKEMIA Most common form of childhood cancer Peak 3-5 years Proliferation of abnormal wbc that do not mature beyond the blast phase Blast cells infiltrate other organs liver, spleen, lymph tissue Types: Acute Lymphocytic leukemia (ALL) 80-85% Acute 75% chance of surviving Acute nonlymphocytic leukemia Includes granulocytic and monocytic types 60-80% will obtain remission 30-40% cure rate
Assessment: Anemia, weakness, pallor, dyspnea Bleeding, petecchiae, spontaneous bleeding, ecchymoses Infection, fever, malaise Enlarged lymph node Enlarged spleen and liver Bone pain Management: diagnosis: blood studies, BMA BMA Treatment stages Induction CNS prophylaxis Maintenance Nursing Intervention: Provide care for the child receiving chemo and radiotherapy Provide support for the family/child Support child during painful procedures Use distraction, guided imagery Allow the child to retain as much control as possible Administer sedation prior to procedure as ordered Sickle cell anemia hemoglobin A is partly partly or completely replaced by abnormal sickle hemoglobin hemoglobin (HgbS) HgbS sensitive to changes in the oxygen content of the red blood cell Risk factors: African American Insufficient oxygen causes the cells to assume a sickle shape and the ce lls become rigid and clumped together, obstructing capillary blood flow The sickling response reversible under adequate oxygenation Sickle cell crises vaso-occlusive vaso-occlusive crisis, splenic se questration, questration, aplastic crisis Assessment: 1. Vaso-occlusive Vaso-occlusive crisis Most common type of crisis Caused by stasis of blood with clumping of the cells in microcirculation, ischemia and infraction Fever, pain and tissue engorgement 2. Splenic sequestration Pooling of blood in the spleen Profound anemia, hypovolemia, shock 3. Aplastic crisis
Caused by the diminished production and increased destruction of RBCs, triggered by viral infection or the depletion of folic a cid Profound anemia and pallor Implementation:
Administer oxygen and blood transfusions administer analgesics maintain adequate hydration and blood flow with IV normal saline as prescribed and with oral fluids Assist the child to assume a comfortable position so that the child keeps the extremities extended to bed no more than 30 degrees avoid putting strain on painful joints encourage consumption consumption of a high calorie, high protein diet with folic acid supplementation administer antibiotics as prescribed Monitor for signs of increasing anemia and shock (pallor, vital sign changes)
New born Screening test Newborn screening screening (NBS) is a simple s imple procedure to find out if your y our baby has a congenital metabolic disorder that may lead to mental retardation and even death if left untreated. Newborn screening screening is ideally done on the 48th hour or at least 24 hours from birth. Some disorders are not detected if the test is done earlier than 24 hours. The baby must be screened again after 2 weeks for more accurate results. Newborn screening screening is a simple procedure. Using the heel prick method, a few drops of blood are taken from the baby's heel and blotted on a s pecial absorbent filter card. The blood is dried for 4 hours and sent to the Newborn Screening Laboratory (NBS Lab). Newborn screening screening results are available within seven se ven working days to three weeks after the NBS Lab receives and tests the samples sent by the institutions. Results are released by NBS Lab to the institutions and are released to your attending birth attendants or physicians. Parents may seek the results from the institutions where samples are collected. A negative screen mean that the result of the test is normal and the baby is not suffering from any of the disorders being screened. In case of a positive screen, the NBS nurse coordinator will immediately inform the coordinator of the institution where the sample was collected for recall of patients for confirmatory confirmatory testing.
Disorder Screened
Effects SCREENED
Effect if SCREENED and treated
CH (Congenital Hypothyroidism CAH (Congenital Adrenal Hyperplasia) GAL (Galactosemia)
Severe Mental Retardation
Normal
Death
Alive and Normal
PKU (Phenylketonuria) G6PD
Death of Cataracts Alive and Normal Severe Mental Normal Retardation Severe Anemia, Normal Kernicterus
http://www.doh.gov.ph/faq/show/457.html
Amniocentesis, Ultrasonography, Leopolds Manuevers, and paracenthesis Amniocentesis Purpose: obtain sample of amniotic fluid by inserting a needle through the abdomen into the amniotic sac Fluid
is tested for:
y y
Genetic screening Determination Determination of fetal maturity primarily by evaluating factors indicative of lung maturity Done with empty bladder Complication:
Most common side effect : INFECTION > Late : pre term labor > Early : spontaneous abortion o - down syndrome q - neural tube defect, spina befida Greenish ± Meconium Stains ( Fetal Distress) Yellowish ± jaundice, jaundice, hyperbilirubinemia Cloudy ± Infection >
Ultrasonography An ultrasound is something like an x-ray. But it uses s ound waves rather than radiation radiation to make black-and white pictures from inside the body. An ultrasound is used in women who are pregnant, or who might be pregnant. An ultrasound might be done more than once during a pregnancy, depending on the health of the baby or mother.
Preparation
& Expectations The woman should wear loose-fitting, two-piece clothes. If done early in the pregnancy, the woman may need to have a full bladder. This can help with getting a clearer picture from the sound waves. A full bladder is not usually needed i n the later stages of pregnancy. http://www.medicineonline.com/articles/O/2/Obstetric-Ultrasonography/PregnancyUltrasound.html
Leopolds Maneuvers Purpose: Done to determine the attitude, fetal presentation, lie, presenting part, degree of descent an estimate of the size, and no. of fetuses Procedure: 1. Fundal Grip place patient in supine position with knees slightly flexed. Put towel under head and right hip. With both hands palpate upper abdomen and fundus. Assess size, shape, movement and firmness of the part and to determine the presenting part nd
2. 2 maneuver with both hands moving down, identify the back of the fetus where the ball of the stethoscope is placed to determine FHT PR of mother: uterine soufflé M HR 3. Pawlicks Grip a. using the right hand, grasp the symphysis pubis part using the thumb and fingers. b. Assess whether the presenting part is engaged in the pelvis. c. Alert! If the head is engaged it will not be movable 4. Pelvic Grip a. the examiner changes the position by facing the patients feet. With two hands, assess the descent of the presenting part by locating the cephalic prominence or brow. b. When the brow is on the same side as the back, the head is extended. When the brow is on the same side as the small parts, the head is flexed and vertex presenting. i. Attitude relationship of fetus to one another. a nother. ii. Full Flexion when the chin touches the chest
Changes during Pregnancy Goodells Sign softening of the cervix Operculum mucous production increase Hegar Sign softening of the isthmus Braxtons hicks contraction mild contraction Ballotment fetus rebounds against the examiners hand when pushed gently upwards
Pregnancy and nutrition: Balanced Balanced diet + 300 cal for pregnant. +500 cal for breastfeeding Pregnancy induce Hypertension -Hypertension disorder of pregnancy after 20 weeks of gestation Manifestation: edema in the arm and describe as tightening of the ring Pre- eclampsia: Elevated weight gain Tinnitus Proteinuria Albumenuria Increase BP Eclampsia: Convulsion in addition of pre-eclampsia Laboratory: + Proteinuria and elevated BP Nursing diagnosis: Altered tissue Perfussion Intervention:
Bed rest Dark room Increase protein MgSO4= antidote Ca glocunate
Medical Surgical Nursing 1. Burns 2. Nursing diagnosis and anesthesia 3. PACU monitoring 4. Pancreatitis 5. Colitis 6. Hepatitis 7. Diabetes mellitus 8. Electrolytes and his/her ECG 9. Myocardial Infarction and his/her ECG 10. Pharmacologic and non-pharmacologic non-pharmacologic pain relief 11. Breast cancer and cervical cancer
Burns
Nursing Diagnosis: 1. Altered tissue perfusion 2. Acute pain 3. Fluid and electrolytes imbalance imbalance Pain Management Administer morphine sulfate or meperidine (Demerol), as prescribed, by the IV r oute Avoid IM or SC routes because absorption through the soft tissue is unreliable when hypovolemia and large fluid shifts are occurring Avoid administering medication by the oral route, because of the possibility of GI dysfunction Medicate the client prior to painful procedure. Topical Drugs Silver sulfadiazine Most widely used agent and least common incidence of side effects May cause transient leukopenia that disappears 2-3 days of treatment Use with either open treatment, light or occlusive dressings Applied once or twice daily after thorough wound cleansing Mafenide acetate 10% cream or 5% solution (Sulfamylon) Painful during and for a while after application May cause metabolic acidosis, not used if >20% TBSA Cream must be reapplied 12 hours to maintain therapeutic effectiveness Solution concentration is maintained with bulky wet dressings, rewet every 2-4 hours h ours Silver nitrate (0.5% solution) Stains everything including normal skin brown or black Monitor electrolyte balance carefully Other topical dressings Cerium nitrate Povidone iodine Gentamycin Polymixin B Bacitracin ointment Electrolytes changes in burns Hyperkalemia, Hyponatermia Burn wound heal by secondary intension
Anesthesia Risk for infection Ineffective breathing pattern Post Operative Care Unit Monitoring Assessment: 1. Mental status 2. VS= every 15 min for 30mins and every 30mins for 1 hour h our every one hour for 2 hours and every 2hours/4hrs 3. Respiratory status 4. Level of pain 5. Surgical site and surgical appliance 6. Level of consciousness 7. Fluid status and reviewing intake and output 8. Neurovascular Neurovascular status of extremities of the client c lient Goals: 1. Airway will be patent 2. VS will be stable 3. Will be alert and oriented when stimulated 4. Respiratory status will be adequate 5. Surgical site will be intact with dry dressing 6. IV will be intact and patent 7. Pain control will be adequate 8. Output within normal level 9. Temperature is in normal 10. Motor and Sensory function will be in adequate level 11. Prevent complication 12. Promote independence with self care 13. Ensure adequate discharge planning and teaching Pancreatitis Is the inflammation of the pancreas. POSSIBLE CAUSES: 1. Alcoholism - chronic 2. Bacterial or viral infection 3. Biliary tract disease - acute 4. Blunt trauma to the pancreas or abdomen 5. Drugs: steroids, thiazide diuretics, oral contraceptives 6. Duodenal ulcer 7. Hyperlipidemia
ASSESSMENT ASSESSMENT FINDINGS: a. Abrupt onset of pain in the epigastric / LUQ area that radiates to the shoulder, substernal area, back, and flank b. Abdominal tenderness and distention c. Aching, burning, stabbing, pressing pain d. Knee-chest position, fetal position, or leaning forward for comfort d/t abdominal pain e. Mental confusion, hypocalcemia irritability f. Nausea and vomiting g. Tachycardia, shock, hypotension h. Dyspnea i. Low grade fever j. Elevated serum amylase / lipase / glucose k. Grey Turners, Cullenss sign l. Chronic steatorrhea m. Jaundice n. Hyperglycemia TREATMENT: PANCREATITIS 1. NPO, TPN, Bland, low-fat, high-protein diet of small, frequent meals with restricted intake of caffeine, alcohol, and gas-forming foods 2. Bed rest 3. I.V. fluids fluids (vigorous (vigorous replacement replacement of fluids fluids and electrolytes) BT: packed packed RBC, RBC, FWB 4. Surgical intervention to treat the underlying cause, if appropriate 5. Maintain position, patency, and low suction of NG tube to prevent nausea and vomiting. 6. Monitor I/O, wt OD, abd girth, electrolytes. 7. Monitor blood glucose levels. 8. Meds: meperidine, H2 blockers, anticholinergics, antacids, Ca gluconate, pancreatic enzyme replacements (Viokase, Pancreatin, Pancrease) 9. Keep the client in semi-Fowlers semi-Fowlers position (if his blood pressure pressure allows) to promote comfort and lung expansion. 10. Keep the client in bed and turn him every 2hrs, or utilize a specialty rotation bed to prevent pressure ulcers. 11. Provide a quiet, restful environment to conserve energy and decrease metabolic demands. Cholecystitis Inflammation of the gallbladder; usually caused by the presence of stones (cholelithiasis), which are composed of cholesterol, bile pigments, and calcium. Therapeutic management: Medical management - Nasogastric suctioning to reduce nausea and el iminate vomiting - Narcotics to decrease pain
- Antispasmodics and anticholinergics to reduce spasms and contractions of the gallbladder - Antibiotic therapy if infection is suspected NURSING CARE: - Teach dietary modification to achieve a low-fat intake because reduced bile flow will reduce fat absorption; supplementation with water-miscible forms of vitamins A and E may be prescribed. - Relieve pain both preoperatively and postoperatively Observe for signs of bleeding (vitamin K is fat soluble and is n ot absorbed in the absence of bile); administer vitamin K preparations as ordered Provide care following a cholecystectomy: c holecystectomy: surgical / laparoscopic laser a. Monitor nasogastric tube attached to suction to prevent distention 1. Maintain patency of the tube 2. Assess and measure drainage b. Provide Provide fluids and electrolytes electrolytes via intravenous route c. Keep the client in a low-Fowlers position d. Have the client cough and deep breathe; splint the incision (incision is high and midline, making coughing extremely uncomfortable) e. Provide care for the client with a T-tube (if the common bile duct has been explored, a T-tube is inserted to maintain patency) TREATMENT OF STONES: CHOLESTEROL DISSOLVENT: Moctanin is administered through a nasal biliary catheter to dissolve stones left in the bile duct after cholecystectomy. Dissolution may take 1 to 3 weeks. Observe the client for anorexia, nausea, vomiting, and abdominal pain.
ORAL BILE ACIDS: Chenodiol ( chenix ) and ursodiol ( actigall ) are administered to dissolve small stones. Side effects include diarrhea ( especially with chenodiol ), e levation of hepatic enzymes,gastritis, and gastric ulcers. Dissolution takes between 6 months and 2 years, and the success rate is only about 30 %
Hepatitis
Irreversible fibrosis and degeneration of the liver Therapeutic Intervention: 1. Rest 2. Restriction of alcohol, hepatotoxic drugs. 3. Vitamin therapy: especially the fat soluble vitamins A, D, E and K and vitamin B (thiamine chloride and nicotinic acid); zinc and calcium supplements 4. Diuretics to control ascites and edema
5. Neomycin and lactulose may be prescribed prescribed for elevated blood ammonia levels (2-4 soft stools) 6. Paracentesis if respiratory distress occurs as a result of ascites 7. Surgical intervention to decrease portal hypertension: a portacaval shunt 8. Esophageal varices management Sengstaken-Blakemore tube: 9. Provide care when a Sengstaken - Blakemore tube is in place a. Maintain traction once the tube is passed and the gastric balloon is inflated to ensure proper placement, elevate bed 30-45 degrees b. Maintain the esophageal balloon at inflated level (30-35mm Hg) up to 4 8 hrs c. Deflate gastric balloon for a few minutes at s pecific intervals if ordered to prevent necrosis d. Gastric lavage as ordered e. Suction orally as necessary because the client is unable to swallow saliva 10. Dietary modification: a. Cirrhosis: 1. Protein as tolerated (80-100g); with increasing liver damage, protein metabolism is hindered 2. High carbohydrate, moderate fat; provides for energy; vitamin, mineral, and electrolyte supplements 3. Low sodium (500-1000mg daily); helps control increasing ascites 4. Soft foods if esophageal varices are present; prevents danger of rupture and bleeding 5. Alcohol contraindicated to avoid irritation and malnutrition b. Hepatic coma 1. Protein: reduced according to tolerance; 15-30g 2. High calorie (1500-2000g) to prevent catabolism and liberation of nitrogen 3. Fluid carefully controlled according to output NURSING CARE: Abdominal girth measurements for baseline data relative to ascites. Skin for presence of jaundice, dryness, petechiae, ecchymoses, spider angiomas, and palmar erythema Signs of hepatic coma such as confusion, flapping of extremities Observe for bleeding Provide special skin care and keep nails trimmed because pruritus is associated with jaundice Maintain the client in a semi-Fowlers position to prevent ascites from causing dyspnea Monitor intake and output, abdominal abdominal girth, and daily weight to assess fluid balance Assist with paracentesis a. Have client void before bef ore procedure b. Assist to a sitting or high-Fowlers high-Fowlers position c. Observe for shock d. Maintain pressure dressing over needle insertion site
e. Bed rest for 24 hrs post. Diabetes mellitus A group of metabolic diseases characterized by elevated levels of glucose in the blood resulting from defects in insulin secretion, insulin action, insulin receptors or any combination of conditions. RISK FACTORS for Diabetes Mellitus 1. Family History of diabetes 2. Obesity 3. Race/Ethnicity 4. Age of more than 45 5. Previously unidentified IFG/IGT 6. Hypertension 7. Hyperlipidemia 8. History of Gestational Diabetes Mellitus CLASSIFICATION OF DM
y y y y y
Type 1 DM (Insulin dependent Diabetes Mellitus) Type 2 DM (Non-insulin dependent Diabetes Mellitus) Gestational DM Diabetes Mellitus diagnosed during pregnancy DM associated with other conditions or syndromes
TYPE 1 DM CLASSIC Ps y Polyuria y Polydipsia y Polyphagia TYPE2 DM Decreased sensitivity of insulin receptor to insulin less uptake of glucose HYPERGLYCEMIA Decreased insulin production diminished insulin action hyperglycemia signs and symptoms NOTE: NEVER administer ORAL HYPOGLYCEMIC A GENTS to PREGNANT MOTHERS! NURSING MANAGEMENT OF DM y Nutritional modification y Regular Exercise y Regular Glucose Monitoring y Drug therapy y Client Education
NUTRITIONAL MANAGEMENT y 1.Review the patients diet history to identify eating habits and lifestyle y 2. Coordinate with the dietician in meal planning for weight loss
y y y
3. Plan for the caloric intake distributed as followsfollows- CHO 50-60%; Fats 20-30%; and Proteins 1020% 4. Advise moderation in alcohol intake 5. Using artificial sweeteners is acceptable
EXERCISE Management
y y y y y y y
1. Teach that exercise can lower the blood glucose leve l 2. Diabetics must first control the glucose level be fore initiating exercise programs. 3. Offer extra food /calories /calories before engaging in exercise 4. Offer snacks at the end of the exercise exe rcise period if patient is on insulin i nsulin treatment. 5. Advise that exercise should be done at the same time every day, The most ideal time to exercise is 15 minutes to 2 hours after a meal. 6. Regular exercise, not sporadic exercise, should be encouraged. 7. For most patient, WALKING is the safe and beneficial f orm of exercise
GLUCOSE MONITORING
y Self-monitoring of blood glucose (SMBG) enables the patient to adjust the treatment y y
regimen to obtain optimal glucose control Most common method involves obtaining a drop of capillary blood applied to a test strip. The usual recommended frequency is TWO-FOUR times a day.
DRUG THERAPY and MANAGEMENT y Because the patient with TYPE 1 DM cannot produce i nsulin, exogenous insulin must be
y
administered for life. TYPE 2 DM may have decreased insulin production; ORAL agents that stimulate insulin production are usually employed.
ENERALITIES 1. Human insulin preparations have a shorter duration of action than animal source 2. Animal sources of insulin have animal a nimal proteins that may trigger allergic reaction and they may stimulate antibody production that may bind t he insulin, slowing the action 3. ONLY Regular insulin can be used INTRAVENOUSLY! 4. Insulin are measured in INTERNATIONAL UNITS or ³iu´ 5. There is a specified insulin injection calibrated ca librated in units RAPID ACTING INSULIN Lispro (Humalog) and Insulin Aspart (Novolog) Produces a more rapid effect and with a shorter duration than any other insulin preparation RAPID ACTING INSULIN ONSET- 5-15 minutes PEAK- 1 hour DURATION- 3 hours Instruct patient to eat within 5 to 15 minutes after injection
REGULAR INSULIN Also called Short-acting insulin ³R´ Usually Clear solution administered 30 minutes before a meal ONSET- 30 minutes to 1 hour PEAK- 2 to 3 hours DURATION- 4 to 8 hours INTERMEDIATE ACTING INSULIN Called ³NPH´ or ³LENTE´ Appears white and cloudy ONSET- 2-4 hours PEAK- 6-12 hours DURATION- 16-20 hours LONG- ACTING INSULIN ³UltraLENTE´ Referred to as ³peakless´ insulin ONSET- 6-8 hours PEAK- 12-16 hours DURATION- 20-30 hours HEALTH TEACHING y Regarding Insulin SELF- Administration y 1. Insulin is administered at home subcutaneously y 2. Cloudy insulin should be thoroughly mixed by gently inverting the via l or ROLLING between the hands y 3. Insulin NOT IN USE should be stored in the refrigerator, BUT avoid freezing/extreme temperature y 4. Insulin IN USE should be kept at room temperature to reduce local irritation at the injection site y 5. INSULIN may be kept at room temperature up to 1 m onth y 6. Select syringes that match the insulin concentration.U-100 means 100 units per mL y 7. Instruct the client to draw up the REGULAR (clear) Insulin FIRST before drawing the intermediate acting (cloudy) insulin y 8. Pre-filled syringes can be prepared and should be kept in the refrigerator with the needle in the UPRIGHT position to avoid clogging t he needle y 9. The four main areas for insulin injection are- ABDOMEN, UPPER ARMS, THIGHS and HIPS. Insulin is absorbed fastest in the abdomen and slowest in the hi ps. Instruct the client to rotate the areas of injection, but exhaust all avai lable sites in one area first before moving into another area. y 10. Alcohol may not be used to cleanse the skin y 11. Utilize the subcutaneous injection technique- commonly, a 45-90 degree angle.
y 12. No need to instruct for aspirating the needle y
13. Properly discard the syringe after use.
LipohypertrophyLipohypertrophy- development of fibrofatty masses, usually caused by repeated use of injection site DAWN PHENOMENON y Relatively normal blood glucose until about 3 am, when the g lucose level begins to RISE y Results from the nightly surges of GROWTH HORMONE secretion y Management: Bedtime injection of NPH SOMOGYI EFFECT y Normal or elevated blood glucose at bedtime, decrease blood glucose at 2-3 am due to hypoglycemic levels and a subsequent increase in blood glucose (rebound hypergycemia) y Nocturnal Nocturnal hypoglycemia followed by rebound hyperglycemia y Due to the production of counter regulatory hormones- glucagon. cortisol and epinephrine y Management- decrease evening dose of NPH or o r increase bedtime snack INSULIN WANING
y Progressive rise in blood glucose from bedtime to morning y Seen when the NPH evening dose is administered before dinner y Management: Move the insulin injection to bedtime ORAL HYPOGLYCEMIC AGENTS y Sulfonylureas y Biguanides y Alpha-glucosidase Alpha-glucosidase inhibitors y Thiazolidinediones y Meglitinides y Chlorpropamide Chlorpropamide has a very long duration of action. This also produces a disulfiram-like reaction when taken with alcohol y Second generation drugs have shorter duration with metabolism in the kidney and liver and are the choice for elderly patients
Diabetic Ketoacidosis
y This is cause by the absence of insulin i nsulin leading to fat breakdown and production of ketone bodies
Three main clinical features: y 1. HYPERGLYCEMIA y 2. DEHYDRATION & electrolyte loss y 3. ACIDOSIS ASSESSMENT ASSESSMENT FINDINGS y 1. 3 Ps y 2. Headache, blurred vision and weakness y 3. Orthostatic hypotension y 4. Nausea, vomiting and abdominal pain Acetone (fruity) breath y 5. Acetone y 6. Hyperventilation or KUSSMAULs breathing y HYPERGLYCEMIA NURSING INTERVENTIONS INTERVENTIONS y 1. Assist in the correction of dehydration y Up to 6 liters of fluid may be ordered for infusion, initially NSS then D5W y Monitor hydration status y Monitor I and O y Monitor for volume overload INTERVENTIONS y NURSING INTERVENTIONS y 2. Assist in restoring Electrolytes y Kidney function is FIRST determined before giving potassium supplements! y NURSING INTERVENTIONS INTERVENTIONS y 3. Reverse the Acidosis y REGULAR insulin injection is ordered IV bolus 5-10 units y The insulin is followed by drip infusion in units per hour y BICARBONATE is not used! MANAGEMENT OF FOOT AND LEG PROBLEM
y Soft tissue injury in the foot/leg formation of fissures and callus poor wound healing foot/leg ulcer
y y y y y y
RISK FACTORS for the development of foot and le g ulcers 1. More than 10 years diabetic 2. Age of more than 40 3. Smoking 4. Anatomic deformities 5. History of previous leg ulcers or amputation
MANAGEMENT MANAGEMENT of Foot Ulcers
y Teach patient proper care of the foot
y y y y y y y y
Daily assessment of the foot Use of mirror to inspect the bottom Inspect the surface of shoes for any rough spots or foreign objects Properly dry the feet Instruct to wear closed-toe shoes that fit well Instruct patient NEVER to walk barefoot, never t o use heating pads, open-toed shoes and soaking feet Trim toenails STRAIGHT ACROSS and file sharp corners Instruct to avoid smoking and over-the counter medications for foot problems
Pharmacologic and non pharmacologic pain relief Non-pharmacologic Non-pharmacologic pain relief Acupuncture (AH-q-punk-sher Acupuncture (AH-q-punk-sher)) is based on the belief that life forces or energy move through the body in specific paths. These paths are called meridians (mer-IH-d-uns). With acupuncture, acupuncture, a needle is put into the meridian that runs to the area where you have pain. This ne edle blocks the meridian which stops or decreases the pain. Aromatherapy (uh-ro-muh-THA Aromatherapy (uh-ro-muh-THAIR-uh-p) IR-uh-p) is a way of using good smells to help you relax and decrease pain Biofeedback teaches your body to respond in a different way t o the stress of being in pain. Teaching your body to relax helps make the pain less. Caregivers may use a biofeedback machine so that you know right away when your body is relaxed. But, often you may not need any machines. Learn to take your pulse. Then take it while making your mind think about "slowing down" your pulse. This can work with breathing, temperature, and b lood pressure too. Breathing exercises are another physical way to help your body relax.Teaching your body to relax helps make the pain less. Breathing in and out very slowly is al l you do. Distraction (dih-STRAK-shun) teaches you to focus your attention on something other than pain. Try playing cards or games, watching TV, or taking a walk. Environment (your surroundings) Being in a quiet place may make it easier for you to deal with the pain. Guided imagery (IH-mij-ree) teaches you to put pictures in your mind that will make the pain less intense.
Heat and cold can help decrease pain. Some types of pain improve best using heat while other types of pain improve most with cold. Laughter It has been said that "10 minutes of belly laughter gives 2 hours of pain-free sleep!" Laughter helps you breathe deeper and your stomach digest (break down) food. Massage is often used to help a person become more relaxed. Have someone gently massage your back, shoulders, and neck Music It does not matter whether you listen to it, sing, and hum or play an instrument. Music increases blood flow to the brain and helps you take in more air. Physical therapy can be helpful with pain that was caused by not moving one part of your body. Radiation can be used to decrease the size of a cancer tumor that is pressing on nerves and causing pain. Self-hypnosis is a way to change your level of awareness. This means that by focusing your attention you can move away from your pain. Spinal cord stimulation is a nerve stimulation technique that is similar to TENS. The difference is that in SCS an electrode (a metal wire) is put near the spinal cord during surgery. SCS also uses mild, safe electrical signals to help control pain. TENS is short for transcutaneou transcutaneouss (trans-q-TAIN-e-us) electrical nerve stimulation (stih-mew-LA-shun). A TENS unit is a portable, pocket-sized, battery-powered device which attaches to the skin. The TENS unit uses mild, safe electrical signals to help control pain. Touch energy therapies come from very old beliefs that life forces or energy move through the body in specific paths. Touch therapies believe disease may cause these paths to become blocked. The therapies use touch to help unblock these paths, and allow the energy to flow normally. Unblocking the paths may help you relax and decrease pain.
Pharmacological Pharmacologic al Pain relief Side effects of Morphine in elderly = PRURITUS and ALLERGIC RXN and R R DEPRESSION. Reason for intrathecal administration = prevent Blood brain barrier. Myocardial Infarction Risk factor: 1. Atherosclerosis Atherosclerosis CAD 2. Thrombus formation 3. Hypertension 4. DM ECG Changes: Inverted T wave and ST segment Nursing interventions: 1. establish a patent IV line 2. provide pain relief; morphine sulfate IV (poor p eripheral perfusion, false + for enzymes) 3. Administer O2 as ordered to relieve dyspnea and prevent arrhythmias arrhythmias 4. Provide bed rest with semi fowlers position p osition 5. Monitor ECG and hemodynamic procedures 6. Administer anti-arrhythmias as ordered o rdered 7. Monitor I & O, report if UO <30 ml/hr 8. Maintain full liquid diet with gradual increase to soft, low salt 9. Maintain quiet environment 10. Administer stool softeners as ordered 11. Relieve anxiety associated with CCU environment 12. Administer anticoagulants, thrombolytics (tpa or streptokinase) as ordered and monitor for S/E 13. Provide client teaching and discharge instruction concerning concerning - effects of MI, healing process and treatment regimen - Medication regimen: name, purpose, schedule, dosage, S/E - Risk factors with necessary lifestyle modification - Dietary restrictions: low salt, low cholesterol, avoidance of caffeine - Resumption of sexual activity as ordered (usually 4-6weeks)
Electrolytes abnormalities and ECG HYPOKA L EMI A h Potassium less than 3.5 mEq/L h SSx of hypokalemia: Weakness, fatigue Decreased GI motility: constipation Positive U Wave on ECG can lead to arrhythmias Metabolic alkalosis Bradycardia Bradycardia (HR 60 to 100 bpm) h Rx for hypokalemia K supplements: Oral KCl, Kalium durule h Foods rich in K: Fruits: Apple, Banana, Cantaloupe Note: Green bananas have more K Vegetables: Asparagus, Broccoli, Carrots Also rich in K: orange, spinach, apricot
HYPE RK AL EM I A h Potassium greater than 5.5 mEq/L h SSx of hyperkalemia: Irritability, excitement Increased GI motility: diarrhea, abdominal cramps Peaked T wave can also lead to arrhythmia Metabolic acidosis
HYPOCALCEMIA h Tetany involuntary muscle contraction h SSx of hypocalcemia: Trousseau sign carpal spasm when BP cuff is inflated 150 to 160 mmHg Chvostek sign facial twitch when facial nerve is tapped at the angle of the jaw h Complications Complications of hypocalcemia: Arrhythmia and Seizure (Calcium deficiency is lifethreatening!) h Nursing management for hypocalcemia: Administer Ca Gluconate IV Must be administered slowly to prevent cardiac arrest Excess Ca Gluconate Ca Gluconate toxicity seizure Antidote for Ca excess: Magnesium Sulfate Monitor for signs of MgSO4 toxicity (BURP): BP low Urine output low RR low P ATELLAR REFLEX A BSENT important! earliest sign of MgSO 4 toxicity Hypocalcemia y Prolonged ST Segment y Prolonged QT segment Hypercalcemia y Shortened ST segment y Widened T Wave
HYPONATREMIA h Low sodium Fluid Volume Deficit Hypotension h The initial sign of dehydration is THIRST (adults) or TACHYCARDIA (infants) (infants) h Nursing Management: Force Force fluids (2 to 3 L/day), administer isotonic IV HYPERGLYCEMIA h SSx: 3Ps (Polyuria, Polydipsia, Polyphagia) h Nursing Management: Monitor Fasting Blood Sugar (Normal FBS is 80 to 100 mg/dL) HYPERURICEMIA h Uric acid is a by-product of purine metabolism h Foods high in uric acid: Organ meats, sardines, anchovies, legumes, nuts h Tophi uric acid crystals h Gout uric acid deposit in joints leading to joint pain & swelling, particularly affecting the great toes. h Nursing Management for Gout: Force fluids (2 to 3 L/day) Rx: Allopurinol [Zyloprim] drug of choice for gout Most common side effect: allergic reaction (maculopapular rash) Rx: Colchicine drug of choice for acute gout h KIDNEY STONES tophi accumulation in kidneys The pain associated with kidney stones is termed RENAL COLIC Nursing Management for Kidney Stones: Force fluids Rx: Morphine Sulfate narcotic analgesics are the drug of choice to re lieve renal colic Side-effect of narcotic analgesics: Respiratory depression , so always check RR before administering Antidote for Morphine overdose: Naloxone [Narcan] SSx of Naloxone toxicity: tremors Strain the urine using gauze Hypomagnesemia y Tall T waves y Depressed ST Segment Hypermagnesemia y Widened QRS y Prolonged PR
Breast
and cervical cancer
Breast Cancer RISK FACTORS 1. Genetics- BRCA1 And BRCA 2 2. Increasing age ( > 50yo) 3. Family History of breast cancer 4. Early menarche and late menopause 5. Nulliparity 6. Late age at pregnancy 7. Obesity 8. Hormonal replacement 9. Alcohol 10. Exposure to radiation PROTECTIVE FACTORS 1. Exercise 2. Breast feeding 3. Pregnancy before 30 y/o ASSESSMENT ASSESSMENT FINDINGS 1. M ASS- the most common location is the upper outer quadrant 2. Mass is NON-tender. Fixed, hard with irregular borders 3. Skin dimpling 4. Nipple retraction 5. Peau d orange LABORATORY LABORATORY FINDINGS 1. Biopsy procedures 2. Mammography MEDICAL MANAGEMENT 1. Chemotherapy Chemotherapy 2. Tamoxifen therapy 3. Radiation therapy SURGICAL MANAGEMENT MANAGEMENT 1. Radical mastectomy 2. Modified radical mastectomy 3. Lumpectomy 4. Quadrantectomy NURSING INTERVENTION : PRE-OP 1. Explain breast cancer and treatment options 2. Reduce fear and anxiety and improve coping abilities
3. Promote decision making abilities 4. Provide routine pre-op care: Consent, NPO, Meds, Teaching about breathing exercise
ost-OP NURSING INTERVENTION : P ost-O 1. Position patient: Supine Affected extremity elevated to reduce edema 2. Relieve pain and discomfort Moderate elevation of extremity IM/IV injection of pain meds nd Warm shower on 2 day post-op 3. Maintain skin integrity Immediate post-op: snug dressing with drainage Maintain patency of drain (JP) Monitor for hematoma w/in 12H and apply bandage and ice, refer to su rgeon Drainage is removed when the discharge is less than 30 m l in 24 H Lotions, Creams are applied ONLY when the incision is healed in 4-6 weeks 4. Promote activity Support operative site when moving nd Hand, shoulder exercise done on 2 day Post-op mastectomy exercise 20 mins TID NO BP or IV procedure on operative site Heavy lifting is avoided Elevate the arm at the level of the heart On a pillow for 45 minutes TID to relieve transient edema 5. MANAGE COMPLICATIONS Lymphedema 10-20% of patients Elevate arms, elbow above shoulder and hand above elbow Hand exercise while elevated Refer to surgeon and physical therapist Hematoma Notify the surgeon Apply bandage wrap (Ace wrap) and ICE pack Infection Monitor temperature, redness, redness, swelling and foul-odor IV antibiotics No procedure on affected extremity 6. TEACH FOLLOW-U P care Regular check-up Monthly BSE on the other breast Annual mammography mammography
Cervical Cancer Risk Factor: -HPV infection: HPV is a group of viruses that can i nfect the cervix. - Lack of regular Pap tests - Smoking - Weakened immune system - many sexual partners - Using birth control pills for a long time - Having many children - DES (diethylstilbestrol) Sign and Symptoms - Abnormal vaginal bleeding -Bleeding that occurs between regular menstrual periods -Bleeding after sexual intercourse,douching, or a pelvic exam -Menstrual periods that last longer and are a re heavier than before -Bleeding after going through menopause -Increased vaginal discharge -Pelvic pain -Pain during sex Stage I: The tumor has invaded the cervix beneath the top layer of cells. Cancer cells are found f ound only in the cervix. Stage II: The tumor extends to the upper part of the vagina. It may extend beyond the cervix into nearby tissues toward the pelvic wall (the lining of the part of the body between the hips). The tumor does not invade the lower third of the vagina or the pelvic wall. Stage III: The tumor extends to the lower part of the vagina. It may also have invaded the pelvic wall. If the tumor blocks the flow of urine, u rine, one or both kidneys may not be working well. Stage IV: The tumor invades the bladder or rectum. Or the cancer has spread to other parts of the body.
Treatment Women with cervical cancer have many treatment options. The options are surgery,radiation therapy, chemotherapy, or a combination of methods.
Surgery Radical trachelectomy: The surgeon removes the cervix, part of the vagina, and the lymph nodes in the pelvis. This option is for a small number of women with small tumors who want to try to get pregnant later on.
Total hysterectomy: The surgeon removes the cervix and uterus. Radical hysterectomy: The surgeon removes re moves the cervix, some tissue around the cervix, t he uterus, and part of the vagina. Radiation Therapy External radiation therapy: therapy: A large machine directs radiation at your pelvis or other tissues where the cancer has spread. The treatment usually is given in a h ospital or clinic. You may receive external radiation 5 days a week for sev eral weeks. Each treatment takes only a few minutes. Internal radiation therapy: A thin tube is placed inside the vagina. A radioactive substance is loaded into the tube. You may need to stay in the hospital while the radioactive source is in place (up to 3 days) Chemotherapy (Side effect) Blood cells: When chemotherapy lowers the levels of healthy blood cells, you're more likely to get infections, bruise or bleed easily, and feel very weak and tired. Cells in hair roots: Chemotherapy may cause hair loss. If you lose your hair, it will grow back, but it may change in color and texture. Cells that line the digestive tract: Chemotherapy Chemotherapy can cause a poor appetite, nausea and vomiting, diarrhea, or mouth and lip sores.
1. Colostomy Care 2. Insulin Administration and rotation 3. Intervention during hypo and hyperglycemia 4. Care for hypo and hyperthyroidism and monitor hypocalcemia 5. Tuberculosis and leprosy late and early Sign 6. Acute and chronic renal failure and hemodialysis 7. Study radiation and chemotherapy and there usual side e ffect 8. Mammography, BSE, TSE, DRE, and colon cancer, changes that occur during elderly, bladder, colon, and cervical diagnostic examination 9. AGN, Osteoatritis and rheumatoid arthritis, Bells palsy and trigeminal neuralgia 10. Laryngeal cancer and traceostomy care
ostomy Care y Referral to enterostomal therapist. y Encourage verbalization of fears/concerns. y Teach character of drainage: ileostomy liquid 4-6x/day, transverse colostomy mushy OD, descending/sigmoid soft formed q 2-3 days y Skin care nystatin, karaya powder, p owder, soap/H2O pat dry y Odor control deodorant drops, bismuth tabs, m outhwash solutions, spinach, parsley added to ostomy bag. y Odor avoid gas-formers (cabbage, beans, broccoli, cauliflower, corn, onions, eggs, fish, condiments. y Diet ileostomy (clear liquids, strained fruits/veggies progress to regular diet, Na/K rich food, avoid fried, seasoned food, nuts, raisins, raw fruits) y colostomy clear liquid, solid low-residue 1st 6 weeks y Ileostomy drainage q 4-6 hrs emptied, pouch 5-7 days max Ostomy Irrigation y Only colostomies are irrigated; ileostomy no need y Purposes ± stimulate emptying of colon to avoid use of appliance y Started 5-7 days post-op in the bathroom preferably y Equipment: irrigating solution, catheter with stoma tip, irrigating sleeve y Tepid water used 18-24 in above stoma (shoulder height) y 500-1000ml irrigated slowly y Done same time everyday / as preferred y Return flow expected within 15-45 mins Insulin Administration
Types Regular (humulin R) Intermediate acting Insulin (NPH, Humulin N) Long Acting Insulin (Ultralente, Humulin U) Combination (70/30)
Onset 30mins- 1hr 2-4hrs
Peak
2-4hrs 6-8hrs
Duration 6-8hrs 12-16hrs
4-8hrs
12-16hrs
24-32 hrs
30mins
2-12hrs
24 hrs
Teaching points y Use the same type and brand of syringe; use the same type and brand of insulin to avoid dosage errors. y Do not change the order of mixing insulins. Rotate injection sites regularly (keep a chart) to prevent breakdown at injection sites. y Dosage may vary with activities, stress, diet. Monitor blood or urine glucose levels, and consult physician if problems arise. y Store drug in the refrigerator or in a cool place out of direct sunlight; do not f reeze
y y y y y
insulin. If refrigeration isn't possible, drug is stable at controlled room temperature less than 30° C (86° F) and out of direct sunlight for up to 28 days; do not freeze insulin. Monitor your urine or blood for glucose and ketones as prescribed. Wear a medical alert tag stating that you are a diabetic taking insulin so that emergency medical personnel will take proper care of you. Avoid alcohol; serious reactions can occur. Report fever, sore throat, vomiting, hypoglycemic or hyperglycemic reactions, rash
Care of Client with hypothyroidism and Hyperthyroidism Hypothyroidism (Myxedema) y Monitor HR including rhythm y Diet: Low Calorie, saturated and fat diet y Thyroid replacement therapy y Assess constipation and provide roughage y Provide warm environment and monitor overdose o verdose of meds
Hyperthyroidism y Provide cool and quite environment y Obtain wt daily and high calorie ca lorie and saturated fat diet y Administer anti thyroid meds Medical Management 1. Prophythiouracil(PTU) block thriod synthesis 2. Methimazole (Tapazole) Inhibit synthesis of thyroid hormone 3. Lugol Solution Decrease size and vascularity vascu larity of thyroid gland; Platable if diluted with water,Milk or juice; give with straw to prevent staining; take 2-4 weeks before the result resu lt are evident. After Thyroidectomy y Monitor respiratory distress; have tracheostomy set, oxygen, and suction mach ine at bed side y Maintain semi fowlers position to reduce edema y Immobilized head with fellow or sand bag to prevent flexion and hyperextension of the head y Limit client talking and assess for client hoarseness y Assess for laryngeal nerve damage= high pitch p itch voice, stridors, dysphagia, dysponia, and restlessness y Monitor for sign of hypocalcemia and tetany have Ca gluconate at bed side
Tuberculosis and leprosy late and early sign
Disease Leprosy
Tuberculosis
Early Sign -Change in skin color either reddish or white -Loss of sensation in the skin lesion -Loss of sweating and hair growth -Thickened and painful nerves -Muscle weakness or paralysis in the extremities -Pain and redness on the eye -Nasal obstruction -Ulcer that do not heal -Asymptomatic -Unexplained wt loss -Night sweat -low grade fever and chills -weakness or fatigue and loss of appetite
Late Sign -Madarosis (loss of eyebrow) -Lagopthalmus (inability to close the eye) -Clawing of fingers and toes -Contractures -Chronic ulcer -Sinking of the nose bridge -Gynecomastia (enlargement of breast
-Cough that last for three weeks and more -Pain in the chest -Hemoptysis
Acute and Chronic renal failure and Hemodialysis Pre
renal Failure cause -Cardiogenic shock -Hypotension -Acute vasoconstriction -Burns -Hemorrhage -Septicemia -CHF Acute Renal Failure Oliguric Phase (all electrolyte Increase because it is retain except Ca) -Hypernatremia -Hyperkalemia -Hyperphostathemia -Hypermagnesimia -Hypocalcemia
Acute Renal Failure cause -Acute tubular Necrosis -DM -Malignant Hypertension -Acute Glomerulonephritis -Tumors -Blood transfusion reaction -Nephrotoxicity
Chronic Renal Failure cause -Calculi -Tumor -Blood clot -BPH -Strictures -Trauma -Anatomic malformation
Diuretic Phase (All electrolytes is decrease because its secrete) -Hyponatremia -Hypokalemia -Hypovolemia
Convalescent Phase (Normal values) -Normal urine volume -Increase level of consciousness -BUN is stable and normal -May develop CRF
Nursing Care: 1. Monitor Fluid and electrolyte balance 2. Monitor alteration in blood volume
3. Promote optimal nutritional status 4. Prevent complication from impaired mobility 5. Prevent fever and infection 6. Support client and reduce/relieve anxiety Chronic Renal Failure Nursing Care: 1. Prevent neurologic complication 2. Promote optimal GI function 3. Monitor and prevent complicati co mplication on of o f fluids and electrolytes 4. Promote maintenance of skin integrity 5. Monitor for bleeding and prevent complication 6. Assess for hyperphostatemia a. Paresthesia b. Seizure c. Muscle cramps d. Abnormal reflexes 7. Administer aluminum hydroxide gel as order 8. Promote cardiovascular function 9. Provide care for client receiving dialysis Hemodialysis -Shunting of blood from the client¶s vascular system through a n artificial dialyzing and returned of dialyzed blood to the client circulation Nursing care before and during dur ing 1. Void the client 2. Chart the clients weight 3. Monitor vital sign before, and every 30mins during the procedure 4. Withhold antihypertensive, vasodilators, and sedatives to prevent h ypotensive episode 5. Ensure bed rest with frequent posi po sition tion to promote comfort 6. Inform that headache and nausea may occur 7. Monitor for sign of bleeding since the blood is heparinized 8. Assess complication a. Hypovolemic shock ±result of rapid removalof fluid from the intravascular compartment b. Dialysis disequiliberium-urea is removed more rapidly from the blood t han the brain. -assess for nausea, vomiting, elevated BP, disorientation, leg cramps, and peripheral paresthesia Acute Glumerolonephritis Nursing Care 1. Monitor I&O, BP, and watch for dehydration 2. Provide diversional therapy 3. Provide teaching and planning concerning: a. Medication administration b. Prevent infection
c. Sign of renal infection d. Importance of long term follow up Rheumatoid arthritis Auto immune connective disorder -Morning stiffness -Range of motion exercises -Encourage -Encourage self care: provide privacy and pain relief -Apply local heat or cold MEDICATIONS -Analgesics -Anti inflammatory drugs CLIENT EDUCATION Serious risk gastric ulceration from anti inflammatory drugs Bells palsy
Bell's palsy is a form of temporary facial paralysis resulting from damage or trauma to one of the facial nerves. Bell's palsy is most often connected with a viral infection such as herpes (the virus that causes cold sores), Epstein-Barr (the virus that causes mono), mono), or influenza (the flu). -some people may have a headache or feel pa in behind or in front of their ears e ars -person may notice one side of his or her face droops or feels stiff -Some people may only notice a slight weakness, whereas others may not be a ble to move that side of their face at all. - difficulty closing one eye all the way - dryness in one eye - trouble tasting at the front of the tongue on the affected side - changes in the amount of saliva or drooling d rooling - hearing sounds that seem louder than usual in one ear - It's important to eat well and get lots of sleep when you have Bell's Be ll's palsy. Good nutrition and rest will help your body as it heals itself. - One of the hardest things about having Bell's pals y can be dealing with the emotions that go with it. Trigeminal neuralgia
Trigeminal neuralgia causes facial pain.Trigeminal neuralgiadevelops neuralgiadevelops in mid to late life. The condition is the most frequently occurring of all the nerve pain disorders. The pain, which comes and goes, feels like bursts of sharp, stabbing, electric-shocks. This pain can last from a few seconds to a few minutes. Colon Cancer Sigmoid colon is the most common site
Nursing Intervention (Pre-op care) 1. Provide HIGH protein, HIGH calorie and LOW residue diet 2. Provide information about post-op care and stoma care 3. Administer antibiotics 1 day prior 4. Enema or colonic irrigation the evening and the morning of s urgery 5. NGT is inserted to prevent distention 6. Monitor UO, F and E, Abdomen PE Nursing Intervention (Post- op care) 1. Monitor for complications Leakage from the site, prolapsed of o f stoma, skin irritation and pulmonary complication 2. Assess the abdomen for return o f peristalsis peristalsis 3. Assess wound dressing for bleeding 4. Assist patient in ambulation after 24H 5. Provide nutritional teaching Limit foods that cause gas-formation and odor Cabbage, beans, eggs, fish, peanuts Low-fiber diet in the early stage of recovery 6. Instruct to splint the incision and administer pain meds before exercise 7. The stoma is PINKISH to cherry red, slightly edematous with minimal pinkish drainage 8. Manage post-operative complication
1. Psychiatric Nursing 2. Musculoskeletal
Level of anxiety and anxiolytic Anxiety- Vague sense of impending doom
Mild Anxiety +1 -Widened perceptual field -Restlessness -Enhance learning capacity -You seem Restless Moderate Anxiety +2 acing RN meds
Severe Anxiety +3 on¶t know what to say or to do irective
Panic
Anxiety +4 aftey uicide
Don¶t touché the client c lient respiratory alkalosis alkalosis bown bag ANTIANXIETY VLAST ME VAIB Valium ate V Miltown - Meal Libreum - L Equanil Aqua Kneel Ativan - Ate Guy Seraks Sera Ulo Tranxene - Transit Schizophrenia
Ego disintegration Impaired reality perception Genetic vulnerability
Vistaril - largavista Attarax Mga bato (rocks) Inderal hindi ralph Busfar sasakay ng bus
Stress ± Diathesis Model Too much stress in the reality will lead client c lient to escape it and go to the fantasy world Biological Theory Dopamine level is High The exact cause is unknown
ffect appropriate, inappropriate, flat, blunt (incomplete emotion) mbivalence torn between 2 opposing forces utism ssociative Looseness Symptoms Negative Hypoactive Withdrawn Apathy
Positive
Hyperactive Sociable Flight of Ideas Talkative
Assess : Content of Thought Nx Dx : Disturbed thought process Planning/ Implementation: Present reality Provide safety Evaluation: Improve thought process
Assess : Hallucinati Ha llucination/ on/ Illusions Nx Dx : Disturbed sensory perception Planning/ Implementation: Present reality Provide safety Evaluation: Improve sensory perception
Assess : Suspicious Nx Dx : Risk for other directive behavior Planning/ Implementation: Present reality Provide safety Evaluation: Eliminate/ minimize risk for ot her-directed violence
Assess : Suicidal Nx Dx : Risk for self directive behavior Planning/ Implementation:
Present
reality Provide safety Evaluation: Eliminate/ minimize risk for self-directed violence Catatonic y Ambivalence y Waxy Flexibility o Iniwan na posture, ganun forever y No favorite word y Negativism
Paranoid Suspicious Tendency to be violent MistrustpScaredpWithdrawn Nrsg. Int: Develop trust 1 to 1 short interaction frequent visit visit foods in sealed container conta iner meds wrapped for violent pt. Doors open Near the door Don¶t touch the pt. Eye contact 1 arms length away call reinforcement Depression and anti depressant ANTIDEPRESSANTS ANTSAAVE PPZ Asendin ± ascending Norpramin ± sabaw ng knorr Tofranil ± Tofu Sinequan ± nood ng Sine Quan ang title Anafranil ± kina Ana Praning Aventyl ± kina Aven T il Midnight tayo Vivactil ± Bye Back till next week Elavil ± Eh love mo ba ako Prozac ± Pero saka na Paxil - Taksil Zoloft ± mag Solo ka
Aftey
Elective
ide effect is low erotonin
euptake
to 4 weeks nhibitor
PPZ
wo to four weeks ri yclic
nti depressant Higher incidence of side effect Serotonin Seroton in and epinephrine is affected ANTSAVE
MAOI- Mono Amine Oxidase Inhibitor All neurotransmitter affected Highest Side effects Avoid tyramine rich food q may lead to HYPERTENSIVE HYPERTENSIVE CRISES
Thiamine rich food vocado ge cheese
eer
hocolate
ermented cheese ickles reserved foods
oy sauce The
Grief Process
y y y y y
Denial no! this cant be true Anger why me, why me, why now Bargaining if something happens, then Ill give something back Depression Im down 2 weeks or or more s/sx major depression Acceptance client acts according to situation
Personality Disorder SCHIZOID I don¶t want people Believes he can stand on his own Never had a best friend friend Avoid groups and social activi act ivities ties no enjoyment Cares more about computers and pets AVOIDANT I avoid people, I fear criticism Have talent but no confidence ANTISOCIAL I break the law as motto As a child,: steal, lie, always get reprimanded Adult ± grand robbery, illegal activi act ivitist tist against aga inst the law, drug addiction, drives fast, unsafe sex, thrill seeker Good talker, charmer, witty manipulator BORDERLINE
my life is an empty glass
Dependent I cant live without you q Self esteem Poor decision making skills Histrionic Excited, dramatic but manipulative Center of attention Narcissistic I love myself Insensitive, arrogant I am the best
Obsessive
Compulsive I am organized Perfectionist Provide time to do rituals Paranoid Suspicious Passive Aggressive Always say yes but resistance is hidden Electro Convulsive Therapy Pre Informed consent NPO 6 8 hours prior Meds Atropine dry mouth Barbituate Sedative Succinylcholine muscle relaxant, prevent seizure Post Side-lying lateral S/E headache, dizziness, TEMPORARY MEMORY LOSS distinct sign 70 110 volts 20 30 seconds ½ hour asleep post Thought
process disturbance Echolalia I repeat what you say Parrots Echopraxia I repeat what you do Word Salad words, no rhyme Clang Association words with rhyme : Dunk, plank, sunk Neologism creation of new words Plinking, hustash Clarification done in case of neologism neo logism Delusion: g et me/ someone will harm the client Persecutory NBI is out to get Religious I am Jesus Christ Grandeur I am the queen o f the world. Ideas of reference Nurses are talking about me. Concrete Association pilosopo pilosopo ³what will you wear?´ ³clothes´
Thought Blocking Eating Disorder Anorexia Nervosa Diet, diet, diet <85% of expected body 3 mos. amenorrhea Karen Carpenter
Eating Disorders Eating Pattern Weight Menstruation
Bulimia
Eat, eat, vomit Normal weight Irregular menstruation Dao Ming Xi Da Ming Sugat/ suka Vomiting Dental caries Wounded knuckles Metabolic alkalosis Metabolic acidosis
Vomiting Fluid Volume Deficit ARRHYTHMIA (fatal complication) Diarrhea Interventions
y y y y
Restore fluid and electrolyte balance ba lance Collaborative regarding menu contract Target weight gain After meals: stay 30 mins 1 hour
Behavior therapy for Anorexia, Psychotherapy for the Personality Disorders, Cognitive therapy for depression Counter transference and Transference Counter transference occurs when the therapist begins to project his or her own unresolved conflicts onto the client. Examples: Nurse Norbert became concerned when he developed p rotective feelings toward to patient alodia. In discussions with a colleague, he realized that the client rem inded him of his sister, leading to counter-transference of those feelings. Transference Of past feelings, conflicts, and attitudes into present relationships, situations, and circumstances. circumstances. Transference evolves from unresolved or unsatisfactory childhood experiences in relationships with parents or other important figures.
Glaucoma and Cataract Glaucoma Increase of intraocular pressure as a result of inadequate drainage of aqueous humor Types: Acute close angle Glaucoma -result from obstruction to outflow to aqueous humor Chronic close angle GlaucomaGlaucoma - follow if untreated attack of acute close Glaucoma Chronic Open angle GlaucomaGlaucoma - result from over production or obstruction to outflow of aqueous humor Acute Glaucoma-result Glaucoma -result from rapid onset of intraocular pressure >50-70mmhg Chronic Glaucoma - a slow gradual onset on IOP >30-50mmhg Normal IO P= 10-21mmhg Halo Vision Prepare the client for TRABECULOPLASTY as prescribed - to facilitate aqueous humor drainage Prepare client for TRABECULECTOMY as prescribed - allows drainage of aqueous humor into the conjuctival spaces by the creation of an opening
Cataract Opacity of the lens Cloudy white pupil or opaque - Surgical removal of the lens, one eye at a time - A lens implantation may be performed at the time of surgical procedure EXTRACAPSULAR EXTRACTION - The lens is lifted out without removing the lens capsule - may be performed with Phacoemulsion PHACOEMULSION - The lens is broken up by ultrasonic vibrations & extracted INTRACAPSULAR EXTRACTION - The lens is removed within its capsule through a small incision PARTIAL IRIDECTOMY - may be performed with lens extraction to pre vent acute secondary glaucoma Crutches, Cane, and Walkers Crutches Gait Two point Gait - Move the right foot with the left crutches at the same time then move the left foot with right crutches at the same t ime Three point Gait (non bearing weight) - move both crut ches forward followed by affected leg and then unaffected leg. Four point Gait (Polio and cerebral palsy) ±move ± move the right crutches forward followed by left foot and then move the left left crutches followed followed by right foot
to Gait (Paralygic with leg braces) ±Move both crutches forward and then swing both legs into crutches at the same time
Swing
Swing
t hen swing both leg through crutches through Gait ± Move both crutches forward and then
Note: Good go to heaven and bad go to hell Cane
y Hold cane in unaffected hand (good) side y Move cane and leg at the same time y The cane handle should be held with the elbow flex at 30 degree it should be at the level of femur Walkers
y The top of the walker should be at the level same of cane with elbow is flex in 30 degree y Advance 6 inches and move to it Crutches y Axillary bars are positioned 1 ½ to 2 inches below the axilla; measure 2 to 3 fingers below the axilla folds y Hand bars are positioned so the elbow are flex in 30 degrees y When lying down measure from anterior axilla to the foot and add t wo inches to the measurement y When standing measure two inches below the anterior axillary folds to the toes; and then tape measure outwards 6 inches away the toes. Cranial Nerves
Meneire¶s Disease - A syndrome also called ENDOLYMPHATIC HYDROPS - refers to dilation of the endolympathic e ndolympathic system by either overproduction or decreased reabsorption of endolymphatic fluid - characterized by tinnitus, unilateral sensorineural hearing loss, & vertigo Nausea & vomiting Nystagmus Severe headaches Feelings of fullness in the ear Hearing loss is worse during an attack Vertigo Tinnitus, as a continuous low-pitched roar or humming sound Preventing injury during vertigo attacks Providing bed rest in a quiet environment Provide assistance with walking Instruct the client to move the head slowly - to prevent worsening of vertigo Initiate Na & fluid restrictions as Rx Instruct to avoid smoking Administer Nicotinic acid (Niacin) as Rx - promote vasodilating effect Administer antihistamines as Rx - reduce the production of histamine & reduces i nflammation Administer antiemetics as Rx Administer tranquilizers & sedatives as Rx - to calm client & allow rest, control the vertigo, N&V LABYRINTHECTOMY - removal of the labyrinth may be performed POST-OP NURSING CARE Assess packing & dressing on the ear Speak to the client on the side of the unaffected ear Perform neurological assessments Maintain side rails Assist with ambulating ambulating Encourage the use of bedside commode Administer antivertiginous& antiemetic medications as Rx Cognitive therapy is the PSYCHOTHERAPY of choice for depression. Study therapeutic milieu - general pt management, environmental manipulation, uses democratic leadership to test new patterns of behavior. Community meeting is the heart of m ilieu therapy. Equipments for immobility : Trochanter roll/sandbags - prevent external rotation of the hips. Pillow to support back, head, arms and shoulders. Footboard to prevent footdrop. Trapeze bar to move the client up in bed. Knee gatch or pillow - to slightly flex the clients knee.
