NCLEX REVIEW – GAPUZ REVIEW CENTER (31 JANUARY – 17 FEBRUARY 2005, PICC, City of Manila)
DAY 1 (31 JANUARY 05) STEPS IN PASSING
Have a Right Attitude THINK POSITIVELY … have a Fresh Start KNOW what YOU WANT and HOW TO GET IT OVERVIEW OF ESSENTIAL CONCEPT TRY OUT Focus assessment 7 habits of SUCCESSFUL EXAMINEE
MOSBY – growth and development LIPPINCOTT – care of the Elderly and Communicable Disease DIGOXIN – monitor the creatinine… “ the TV DOESN’T look good to me” (DIGOXIN TOXICITY – nausea/vomiting, abdl cramps) Olive = butter CK – normalize 1 – 3 days after MI LDH - 10 – 14 days ATRIAL FLUTTER – SAW TOOTH PROCESS OF ELIMINATION
consider MASLOW’s H of NEEDS consider the COMPLICATION whether ACUTE CHRONIC ABCs SAFETY FIRST NSG PROCESS
– ALWAYS prioritize
MMR VACCINE – only vaccine for HIV pt. Pt on HEPARIN – APTT (N 30-40sec), therefore if INCREASE – bleeding POISON - nursing action in order : #1 CALL poison control center # 2 MINIMIZE EXPOSURE of pt to poison – pull him/her away from the poison # 3 IDENTIFY the poison GENTAMYCIN
– s/e tinnitus, vertigo, ototoxicity, oliguria
LITHIUM CARBONATE
– for ELDERLY : N level NOT more than 1.0meq/L ADULT : N .5 – 1.2 meq/L
HEPA B diet : low fat, increase CHON
DOWN SYNDROME – large tongue – feeding problem – poor sucking (infants) SAFETY PRINCIPLE 1. when can a child USE ADULT SEAT BELT? - if the infant is 40 lbs and 40 inches in height seat belt location in car: BACK CENTER SEAT 2. TODDLER – falls 3. SUPRATENTORIAL craniotomy – semi fowler’s position INFRATENTORIAL – flat in bed 4. SCATTER RUGS – osteoporosis pts. 5. TRIAGE ; burns, open fx – “SHOCK” Things NOT TO BE DELEGATED by RN: Assessment, Teachings, Evaluation Pt 50y/o and
- mammogram – once a year.
Pt with PKU – LOW PHENYLALAMINE DIET (NOT phenyl FREE). – therefore LOW CHON Pt with Rocky Mountain Fever – exposure to dog ticks Lyme’s Dses – deer ticks PSYCHE PATIENTS 1. remember to stick to unit rules/policy – be consistent to pt. 2. encourage verbalization – “tel me how…..” 3. sound knowledge of cultural diversity - seek help of interpreter 4. acknowledge pt feelings – “it seems….” “this must be difficult…..” 5. emphatize with your patients’s feelings “ I understand how you feel…..” CATARACT – CAUSES – aging and trauma MRSA (methicillin resistant staphyliccocus aureus) - USE GLOVES AND GOWN WHEN W/ PT
DAY 2 ( 01 February 05)
TUBES 1. GROSHONG CATHETER HICKMAN BROVIAC
- 2 lumen - 3 lumen - 1 lumen
ALL requires Central Venous Access - sites: cephalic, brachial, basilica and superior vena cava PURPOSE:
For TPN Administration of Chemo Agents, Blood Products, Antibiotics
COMPLICATION:Thrombosis and Bleeding 2. CHEST TUBES – Water Sealed Drainage Types: Anterior – w/c drains AIR Posterior - w/c drains FLUIDS Water Sealed Drainage : 1 bottle, 2 bottle and Three bottle system 1 BOTTLE :
3 – 5cm of only (length of tube to be emerge)
2 BOTTLE :
First bottle – drainage bottle (no tube emerge), 2nd bottle - long rod 3-5cm
3 bottle
FREQUENTLY USED
:
1st bottle – drainage 2nd bottle – water sealed 3rd bottle – suction bottle control COMPLICATIONS:
bubbling, breakage, blockage
Nsg ALERT:
NORMAL : BUBBLING is N in the 3rd bottle – it indicates that suction is ADEQUATE (if no bubbling STOPS in the 3rd bottle, meaning – inadequate suction)
ABNORMAL : if bubbling occurs at the 2nd bottle – indicates LEAKAGE – action, check sealed at air tight container and the pt and bottle connection.
In case there BREAKAGE, have extra bottle and emerge tube ASAP to prevent entry of air and or may use forcep to clamp tube temporarily. If pt. ambulates, keep bottle LOWER than the patient. ABSENCE of OSCILLATION at the 2nd Bottle – indicates blockage TOWARDS THE BOTTLE - When MILKING the tubings. EMERGENCY EQUIPMETS AT BEDSIDE: xtra bottle,clamp, gauze
3. TRACHEOSTOMY TUBE - to maintain patent airway for pt w/ neurological problems and musculoskeletal disorders.
nursing care: 1. Suctioning – 10-15seconds - if (+) bradycardia, STOP - if accidentally dislodge, insert obturator to keep it open 2. AVOID: water sports – swimming 3. In changing ties – insert new one first BEFORE REMOVING old tie. 4. Ribbon or ties @ side of the neck only to avoid pressure. 5. Before and After suctioning – hyperoxygenate the patient.
4. PTCA
– enlarge the passageway for bloodflow. problem: spasms that lead to arrhythmia
C-STENT (cardiac-stent) – alternative to PTCA Maintains patency of bld vessels Problem: dislodge IABP (Intra Aortic Balloon Pump) - for Cardiogenic Shock problem: thrombus formation, infection and arrhythmia
5. PENROSE DRAIN - wound drainage system - doctors the one who removes this. - remove gradually
6. NASO GASTRIC TUBE – stomach and intestine (duodenum) Types: Levine Tube – for stomach - 1 lumen, for lavage (cleaning) and gavage (feeding)
Salem Sump – for stomach - 2 lumen (I for suctioning, I for lavage/gavage) - if pt (infant) is having enteric coated meds, request for change in form of meds
Miller Abbot – for intestinal (w/ mercury b4 injection) - 2 lumen (insert then inject the mercury)
Cantor – for intestinal - 1 lumen
Nursing Care for NGT: 1. tip of nose to earlobe to xyphoid process (for stomach) 2. tip of nose to earlobe to XP + 7-10 inches for intestinal NGT 3. accurate means to verify correct placement: ALWAYS consider Two checking criteria: ASPIRATION and Gurgling Sounds
Report the following:
If (-) or decrease drainage, (+) nausea and vomiting (+) abdml rigidity Characteristic of Gastric Residual: more than 50 mo and coffee ground. Before feeding check for placement.
7. GASTROSTOMY TUBE (GT) PEG • both for NUTRITIONAL PURPOSES GT – incision (abdomen to stomach) - for pt (+) lesion at esophagus - nsg care : report s/s of infection, abdl cramps, n/v - provide adequate skin care PEG – incision at skin - long term therapy
8. T TUBE - to drain excess bile until hearing occurs - place drainage bag at the level of t-tube (obstruction of t-tube – there will be excess drainage) 500 ml – N drainage in 24hrs, if report ASAP.
9. HEMOVAC JACKSON-PRATTS (JP)
BOTH used as close wound drainage suction system BOTH system function on the system of (-) pressure.
JP – compress the container before attaching to the drainage. WHEN TO EMPTY: when its usually 1/3 to ½ full then RECORD the amount.
10. THREE-WAY FOLEY absence of clot – effective Characteristic of drainage – 2-3 days after surgery (bloody to pinkish) – NO NEED TO REPORT THIS – it is expected
11. SUPRAPUBIC CATHETER – for genito urinary problem - inserted directly at the bladder wall - check if properly anchored 12. URETHRAL CATHETER – to drain urine. - never clamp because it can only hold 4-8 ml of urine. - keep open to drain urine from kidney pelvis. SENGSTAKEN BLAKEMORE TUBE - 3 lumen ( for esophageal balloon, gastric balloon, for meds) - for pt w/ esophageal varices - balloon tamponade - 48 hrs – keep balloon inflated for 10 minutes to decrease bleeding LINTON TUBE
– 3 lumen
MINESOTTA TUBE
– 4 lumen
SCISSORS – important EQUIPMENT AT BEDSIDE FOR ALL TUBES. HEMOSTAT – important instrument that shld be @ bedside for water sealed drainage. Persistent bubbling at water drainage bottle – for bottle #2 – check if tubing is properly sealed. NGT IS REMOVED – if patient exhibits return of bowel sounds. BULB SYRINGE – use to clean the nares of pt with NGT (child) To facilitate removal of air at lungs – purpose of water sealed chamber in 3 way bottle system.
THERAPEUTIC DIET GENERAL CONSIDERATION
Know the DIAGNOSIS of the patient Identify & incorporate the pt. dietary preferences Instruct pt on what to avoid For pregnant pt, note dietary changes: a. addtl calories (300 cal/day) average of 2400 - 2700 b. addtl of 10gms/day for CHON c. IRON : 15-30mg/day d. CALCIUM : RDA is 1000 then +200mg/day (broccoli,tuna,cheese) e. Galactogogues – increase production of milk
PEDIATRIC pt – by 4-6 mos – START iron supplement due to iron depletion and (-) extrusion reflex. - cereals, fruits, vegetables,meat and table foods - egg yolk (6mos), egg white (1yr)
TRANSCULTURAL CONSIDERATION CHINESE – like cold desserts after surgery for optimum health JEWS – “kosher diet” (no meat and diary products at the same time) EUROPEANS – main meal is served at mid day followed by espresso MUSLIM – “halal diet” – no pork SDA – strictly vegs diet (vit B6 and B12 deficiency) MORMONS – words of wisdom (no caffeine, alcohol and once a month fasting) – the amount due for food is donated to the church
KEY POINTS FOR NURSES Sodium (Na) – source down the soil Potassium (K) - source up the tree Low Na Diet : AVOID processed foods, milk products and salty foods KNOW the serving:
CHO - 6-11 servings CHON - 2-3 FRUITS & Vegs - 3-4 FATS - sparingly
MOST COMMON DIET
CLEAR LIQUID DIET (light can pass thru it, meaning TRANSPARENT) - given to pt to relieve thirst, correct fld & electrolyte imbalance - given also to pt post-op ex: apple juice, gelatin (strawberry), popsicle, candy
RENAL DIET -
for kidney disorder (renal failure, AGN, Nephrotic syndrome) to maintain fld & e imbalance
LOW CHON – avoid poultry products LOW Na - avoid processed foods, milk products, & salty foods Low K - avoid fruits (anything you see in a tree)
LOW FAT/CHOLESTEROL RESTRICTED DIET
- for liver disorder, cardiovascular and renal dses ALLOWED: lean meat, fruits, vegs and fish AVOID : Sea foods, fried foods, preserved foods
(cheese cake and custard)
HIGH FIBER DIET - to prevent constipation, hemorrhoids & diverticulitis - vegs, fruits and grain products
SOFT DIET -
PURINE RESTRICTED DIET -
for peptic ulcer, inflammatory GI conditions AVOID: chemically and mechanically irritating foods such as fried foods, fresh and raw fruits & vegs (EXCEPT: avocado, banana & pinya) and spicy foods with preservatives
HIGH PROTEIN, HIGH CARBO DIET -
for cardiovascular dses, renal, fld & e imbalance ALLOWED: fresh vegs AVOID : processed foods, milk products and salty foods
BLAND DIET -
for gouty arthritis increase fluid intake AVOID: preserved foods, sea foods, alcohol, organ meat (liver, gizzard)
NA RESTRICTED DIET -
for inflammatory conditions: esophagitis, peptic ulcer gastritis pureed foods/ blenderized foods soup
for burns (about 5000 cal/day) grain products and poultry – to aid the healing tissues
ACID ASH DIET -
to decrease the ph of the urine indicated for pt w/ alkaline stone ex struvite ex. 3 C’S – cranberry, cheese, & corn 3 P’S - prunes, plums & pastries
ALKALINE ASH DIET -
GLUTEN-FREE DIET -
for PKU, until age 10 and adolescence only AVOID : CHON rich foods (meat products – luncheon meat)
FULL LIQUID DIET -
“ABGs”
for celiac dses ALLOWED : rice, corn, cereals, soy beans AVOID (LIFETIME): barley, rye, oats, wheat
PHENYLALANINE DIET -
to increase ph of the urine indicated for acid stone ( uric acid stone, cystine stone) ex. Milk
opaque transitional diet from liquid ex : cream soup, ice cream, milk, leche flan, pumpkin cake
ATERIAL BLOOD GASES
Ph – 7.35 – 7.45 PCO2 - 35 – 35 HCO3 - 22 – 26 meq/L Ph
Compensatory Mechanism
Uncompensated abnormal Partially compensated abnormal Fully Compensated normal
no change increase or decrease increase or decrease
Diarrhea – metabolic acidosis Vomiting – metabolic alkalosis
PRIORITIZING of case: Med.-Surg – “abc” Psyche - safety first Fire - race Triage - pt evaluation system (prioritizing)
APGAR SCORING
0 Appearance Pulse Grimace Activity Respiratory
1 pallor
(-) (-) flaccid (-)
2
acrocyanosis <100 >100 grimace vigorous some flexion irregular lusty cry
all pink flexion & extension
T.R.I.A.G.E -prioritizing LEVEL 1 “emergency”
severe shock, cardiac arrest, cervical spine injury, airway compromise, altered level of consciousness, multiple system trauma, eclampsia
LEVEL 2 “urgent (stable)”
can be delegated (fever, minor burns, lacerations, dizziness)
LEVEL 3
chronic/ minor illness (can be delegated) – dental problems, routine medications and chronic low back pain
TIPS ON PRIORITIZING 1. PT @ ER – sleeping pills overdose; 2. pt bp 80/30 & mother died of CVA 1st priority : assess pt for addtl risk factor; 3. pt ask what procedure: Rn Action : notify the doctor 4. MI attack – 1st action : report ASAP (esp. presence of vent. Fibrillation) 5. pt on NGT – check patency of tube
DELEGATION -
do not delegate Assessment, Teaching and Evaluation do not delegate meds preparation, administration, documentation
CONCEPT OF DELEGATION
consider the competence of personnel 5 R’s in delegating (RIGHT task, person, circumstances, direction/communication supervision) RN may delegate – feeding client, routine vital sign (pt w/ no complications) and hygiene care
MI ATTACK – enzymes to increase IN ORDER - #1 #2 #3 #4
myoglobin troponin CK LDH
RISK FOR INJURY – meniere’s dses INEFFECTIVE BREATHING PATTERN – myasthenia gravis ALTERED TISSUE PERFUSION – pt w/ complete heart block INEFFECTIVE AIRWAY CLEARANCE – pt w/ kussmaul’s breathing D
DAY 3 ( 02 February 05)
POSITIONING FOR SPECIFIC SURGICAL CONDITION Positioning a. b. c.
– independent nsg function know the purpose of the position to prevent or promote soothing; what to prevent or promote; know your anatomy & physiology
Post Liver Biopsy
– R side lying – to prevent bleeding
(during the procedure – L side lying). Hiatal Hernia
– upright to prevent reflux.
AMPUTATION complication: hemorrhage (keep tourniquet @ bedside) 1st 24hr – goal: to decrease edema – elevate the stump at foot part w/ the use of pillow AFTER 24hr – goal : to prevent contracture deformity (keep leg extended)
APPENDICITIS Unruptured : any position of comfort
Ruptured : semi to high fowler’s position to prevent the upward spread of infection complication: peritonitis Ruptured appendicitis indication: pain decreases or go away. (pt say, “I want to go home pain is gone”)
BURNS Position is FLAT or Modified Trendelenburg – to prevent shock.
SHOCK occurs w/in 24-48hrs (immediate post burn phase). Complication: infection
CAST, EXTREMITY Elevate the Extremity – to prevent edema (use rubber pillow)
Nsg care: a. b. c. d. e.
capillary refill – N 1-3 seconds only (complication: altered circulation) note for s/s of infection (when there is musty odor inside the cast) pruritus (inject air using bulb syringe) blood stained – mark and note (if increasing in diameter - report ASAP) tingling sensation – indicate nerve damage
CRANIOTOMY Types:
a. Supratentorial C – semi fowler’s orlow fowler’s position – to prevent accumulation of fluid at surgical site; b. Infratentorial C - flat or supine. Purpose: same
FLAIL CHEST (+) Traumatic Injury – paradoxical chest movement – areas of chest GOES IN inspiration and OUT on Expiration
position: towards the affected side to stabilize the chest.
GASTRIC RESECTION -
HIATAL HERNIA -
to prevent dumping syndrome – usually for 10 mos only NOT LIFETIME disorder (post gastrectomy) position : LIE FLAT for 1-2hrs post meal
there is damage to esophageal mucosa what to prevent: gastric reflux therefore FEEP PT IN UPRIGHT POSITION.
HIP PROSTHESIS Position: to prevent subloxation (KEEP LEG ABDUCTED) with the use of wedge pillow or triangular pillow from perinium to the knees. dumping syndrome : “flat”
LAMINECTOMY -
“log-roll the patient” (3 nurses) – KEEP SPINE IN STRAIGHT ALIGNMENT
-
LIVER BIOPSY -
before LB : supine or L side lying to expose the part during LB : - doafter LB : R side lying w/ small pillow under the coastal margin to prevent bleeding.
LOBECTOMY -
AVOID: hyperflexion, hyperextension and prone – it causes hyperextension of the spine.
removal of Lobe (N R lobe – 3, L lobe – 2) position : semi fowler’s position – to promote lung expansion
MASTECTOMY -
removal of breast elevate or extend affected arm to prevent lymp edema (or elevate higher that the level of the heart. AVOID: venipuncture, specimen taking, blood pressure – ON THE AFFECTED ARM coz there is no more lymph node w/c predispose pt to bleeding. Post mastectomy Exercises:
squeezing exercises, finger wall climbing, flexionextension (folding of clothing, washing face, vacuuming the house)
Due to removal of axillary lymph node, avoid also gardening and hand sewing
PNEUMONECTOMY -
RADIUM IMPLANT OF THE CERVIX -
either L or R lung. Position pt on the AFFECTED SIDE to promote lung expansion.
keep pt on complete bed rest to prevent dislodge. AVOIDE SEX (may burn penis bec of the implant inside)
RESPIRATORY DISTRESS Adult : Orthopneic position – over bed table then lean forward Pedia : TRIPOD – lean forward and stick out tongue to maximize the Airflow
RETINAL DETACHMENT
-
to prevent further detachment, place pt on the AFFECTED SIDE.
Ex. If operation is on the R outer of the R eye, place pt on the R position. If operation is on the L inner of the R eye, position pt on the L side AVOID: sudden head movement.
VEIN STRIPPING -
keep extremities extended then elevate the legs at level of the heart to promote venous return
TIPS liver biopsy is done on a pt. – during 1st 24hrs after the procedure, turn the pt on his abdomen w/ pillow under the subcoastal area; when draining the L lower lobe of the lung – the pt shld be positioned on his R side w/ hip higher or slightly higher than the head; after tonsillectomy – position: prone a pt is about to go on thoracenthesis - how shld the nurse position the pt? – sitting w/ a arms resting on the overbed table; to maintain the integrity of pt w/ hip prosthesis – abduction splints immediately after supratentorial craniotomy- fowler’s position best position for pt in shock – supine w/ lower extremities elevated
THERAPEUTIC COMMUNICATION 1. DON’T ASK WHY – this put pt on the defensive 2. AVOID PASSING BACK – “I will refer you to….” 3. DON’T GIVE FAKE REASSURANCE – “everything will be alright….” “you’re in the hands of the best” 4. AVOID NURSE CENTERED RESPONSE – “I felt same too…” “I had the same feeling….” In GROUP DISCUSSION – nurse is just a facilitator – let the group decide, he/she channel are concern back to the group. THERAPEUTIC PHRASES – it seems… you seem…. - open ended question - close ended – for manic pt and pt in crisis - direct question- for suicidal pt
ISOLATION PRECAUTION Purpose : to isolate infection transmission TYPE
PRIVATE ROOM
HAND WASHING
GOWN
GLOVE
MASK
STRICT
(airborne dses, direct contact-Diptheria)
RESPIRATORY
OPTIONAL
OPTIONAL
(AIRBORNE: BEYOND 3FT DROPLET : W/IN 3FT)
TB
OPTIONAL
OPTIONAL
(negative airflow room)
CONTACT
(direct contact – NOT AIRBORNE DSES) eX SCABIES
ENTERIC
X
(fecal contamination)
DISCHARGE X (drainage: pus ex burn pt) UNIVERSAL
(AIDS, HEPA b – TRANSMITTED BY BLD AND DODY FLUIDS)
OPTIONAL
OPTIONAL
OPTIONAL
OPTIONAL
X
TIPS:
When implementing universal precaution, w/c nsg action require intervention: recapping the needle – this might prick your hand;
When discarding the contents of the bed pan use by a pt under enteric precaution – GLOVE IS NECESSARY;
A nurse is giving health teaching to the parents of child with scabies: family member must be treated;
Preventing pediculosis in school age children: avoiding contact w/ hair articles of infected children like clips, head bands, hats – no sharing
Patient with full blown AIDS is placed on isolation precaution – pt ask nurse why his visitors is wearing mask – response: it will help in the prevention of infection;
Essential when a pt w/ meningitis is kept in isolation: isolation precaution remains until 24hrs after initiating antibiotic therapy
DIAGNOSTIC PROCEDURES side notes: pt for IVP pt for KUB schilling test USG
: : : :
assess for allergy (cleansing enema b4 the procedure) no dye (don’t assess for allergy) 24hr urine specimen no consent required
GENERAL CONSIDERATION
•
-
EXPLAIN the procedure to the pt (initial nsg action) if not ready inform the doctor; pt has the right to refuse procedure; doctor the one who asked for consent
•
Check pt for CONSENT – if INVASIVE – WITH CONSENT NON INVASIVE – NO CONSENT needed
•
CONTRAST MEDIUM – check for allergy
•
For procedure requiring anesthesia – KEEP PT NPO B4 PROCEDURE When local anesthesia used – NPO, 1- 2HRS AFTER General anesthesia – keep NPO at least 8hrd after (check gag reflex before meals)
•
PEDIATRIC PATIENT – use flash cards, games and play to encourage participation
TRANSCULTURAL CONSIDERATION
HISPANIC PATIENT – women prefer same gender health care provider Obtain help of interpreter when explaining procedures – (except or don’t ask family members) For muslim patient - they prefer same sex health care provider however, if procedures require life threatening – they prefer to have male doctor. - they only want good news information of their condition
DELEGATION and DOCUMENTATION
Delegation – assessment, monitoring and evaluation of treatment (cannot be delegated) BUT standard and changing procedures can be delegated ex. – 24hr urine specimen and urine catheter
collection. Documentation – type of treatment and any untoward reactions.
KEYPOINTS FOR NURSES
Prepare the patient; Monitor for adverse reaction; Report complication to the doctor
FRAMEWORK – includes the Purpose, Special Consideration and Interpretation
DIAGNOSTIC TESTS (to evaluate FETAL GROWTH AND WELL-BEING)
DAILY FETAL MOVEMENT Purpose : to determine fetal activity by counting fetal movements – usually perform by pt himself
N Fetal Movement
10-12 for 12 hr period (average: 1 movement/hr with average 3fm/hr)
NON STRESS TEST (NST) – correlates fetal heart rate w/ fetal movement -
monitor the baseline FHR then induce fetal movements by (HOW) : a. ring a bell b. feed the patient
then check FHR, NST is (+) if FHR increase at least 15 beats/min than the baseline. (ex. 140 FHB baseline, then after challenge it increase to 155) POSITIVE result means, BABY is REACTIVE (good condition) and no need for contraction stress test/oxytocin challenge test – coz baby is OK and doing well.
CONTRACTION STRESS TEST (oxytocin challenge test) -
correlates FHR with uterine contractions pt on NPO get baseline FHR then induce uterine contraction
HOW: Thru breast stimulation – it triggers the release of oxytocin from pituitary gland… If (-) patient is given Oxytocin – onset is 20-30 minutes. Then check FHR and note the presence of DECELERATION (slowing of FHR) types of deceleration a. early deceleration – indicates head compression (MIRROR IMAGE)
b. late deceleration – indicates placental insufficiency (REVERSE MIRROR IMAGE) mgt: L Lateral Recumbent Position, Administer O2, Treat Hypotenson
c. variable deceleration – due to cord (image: U or W shape) and slowing of FHR can occur anytime.
If (+) CST, meaning there is deceleration, baby is NOT OK coz there is decrease FHR and during labor he/she may stand the labor process.
BIOPHYSICAL PROFILE –
to determine fetal well being w/ the use of 5 CRITERIA
fetal breathing movement heart tone reaction to NST amniotic fld volume
2 points 2 points 2 points 2 points 2 points 10 points
score below 6, indicates fetal jeopardy
ULTRASOUND - provide data on placenta (age and location) gender of baby structural abnormalities position of baby - for pregnant: site is lower abdominal USG
types: a. Upper USG – NPO b. Lower USG - NPO - preparation: increase fluid intake (oral) NO consent needed If pt ask if it is painful: NO PAIN; Pt shld have full bladder CHORIONIC VILLI SAMPLING – CVS AMNIOCENTESIS – AMNIO PERCUTANEOUS UMBILICAL CORD BLOOD SAMPLING – PUBS
CVS Purpose: to detect chromosomal Aberration (eg. Down syndrome, Trisomy 21) Done in 1st trimester (can be done as early as 5th wk but can be done on 8-10th wk)
Get sample at chorion (by 10-12wks – The placenta matures, get some sample)
AMNIO Purpose : same w/ CVS
PUBS Purpose: to check chromosomal aberrations, & presence of RH Incompatibility
can be done on the 2nd wk (14-16 wk) - but not recommended bec. of danger abortion (assess pt age of gestation)
Extract blood at umbilical cord then it is tested if it really comes from the umbilical cord (can be done on either 2nd or 3rd tri.
or can be done on the 3rd wk (34-36 wk) purpose: to detect fetal maturity (FLM) thru monitoring of L/S Ratio N 2:1 (if mother is (+) DM LS ratio is 3:1) This procedure also check level of alpha-feto Protein – if INCREASE – spina befida; If DECRTEASE – down syndrome
(+) Consent – invasive
(+) Consent
Bladder : Empty
consider the Pt Age of Gestation (if age of gestation :
(+) Consent
is higher than 20wks and above : empty bladder, if AOG is 20wks and below : full bladder
COMPLICATIONS of CVS, AMNIO & PUBS: a. b. c. d.
infection bleeding abortion fetal death
TIPS
• EARLY DECELERATION – expected in the fetal monitor when there is fetal head compression;
• AMNIOCENTESIS – was done @ 35 wks gestation – purpose: to determine fetal lung maturity;
• A mother asked the nurse what will amniocentesis provide during pregnancy: it will show as whether the baby lungs are developed enough for the baby to be born;
• a nurse is preparing pt for lower abdl usg – w/c of the following done by the pt needs further teaching – pt voids b4 the procedure;
• after amniocentesis w/c of the following manifestation if observed by the nurse on the patient that needs to be reported : bleeding; • heart rate;
pt ask the nurse – what deceleration means – it refers to slowing of baby’s
•
before Amniocentesis, what to check – USG DEVICE
DIAGNOSTIC TESTS (to evaluate pediatric patients) CARDIOPNEUMOGRAM – use to diagnose apnea of infancy – assess HR, RR, nasal airflow and O2 saturation – N 95-98% below 85 – report ASAP GLUTEN CHALLENGE - detect presence of Celiac Disease (CD) - intolerance to gluten; - pt is given gluten rich food for 3-4 months the observe s/s of CD s/s of CD:
abdl cramps, steatorrhea, abdl rigidity, abdl distention (if + for CD, gluten free diet will be for life time)
ORTOLANI’S TEST (OT) purpose: test developmental dysplacia of the hip or congenital hip dislocation (+) if w/ click sound (lateral)
BARLOW’S MANUEVER (BM) purpose : same (+) barlow’s click – press downward and w/ click sound
POLYSOMNOGRAPHY or “sleep test” -
EEG is connected to pt when he sleeps Check the brain waves, check for apnea of infancy preparation : No Special prep, HOLD CAFFEINE FOOD – 2days b4 test
SCOLIOMETER -
measure the degree or angle of scoliosis check for: (+) scoliosis if uneven hemline uneven waist more prominent iliac rest and scapula on one side presence of rib hump
test for pre-teen : “bend over test” – bend and touch the toe; (+) scoliosis – if presence of rib hump, therefore x-ray then scoliometer. SICKLEDEX TEST
HGB ELECTROPOISIS
Purpose: test for sickle cell anemia
Purpose: test for sickle cell anemia
Specimen : Blood : (blood + solution, if (+) TURBID Specimen : Blood : bld + electropoiesis, if sickling of RBC Therefore TRAIT CARRIER (S or C shape RBC), therefore + for SC Dses Test for TRAIT
Test for Disease
GUTHRIE CAPILLARY BLOOD TEST (GCBT) - to detect PKU (in PKU there is absence of PHENYLALAMINE HYDROXYLASE- PH) Phenylalamine hydroxylase – is an enzyme that converts PH to Tyroxine – the one that gives color to hair, eyes and skin. If absent PH, no one will convert PH to Tyroxine, therefore it will accumulates to brain and can cause mental retardation. PH came from CHON rich food. At birth, it is usually negative, so give CHON food first for 3wks then retest. Before test, give chon rich food for 1-4 days before test. (adult) N PH level - >2mg/dl (if 4mg/dl – indicative of PKU, 8mg/dl – confirms PKU)
SWEAT CHLORIDE TEST -
to detect Cystic Fibrosis (in CF, the skin becomes impermeable to Na. meaning cannot reabsorb Na and it accumulates outside of the skin); Mother complain that her baby taste salty; PILOCARPINE – used in the test to induce sweating;
Types: a. sweat chloride test – N 10-35 meq/L (above 40 meq/L– (+) b. serum chloride test – N 90-110 meq/L (above 140 meq/L – (+)
TIPS
pt w/ PKU would more likely to have (+) result in gluten capillary bld test if there is – adequate CHON in the diet;
mother complains that her baby taste salty – which test is to be performed : sweat chloride test;
9 yo pt has (+) result for sweat test – this indicates possible dx of Cystic Fibrosis;
pilocarpine – drug used for pt undergoing seat chloride test;
hgb electropoisis – test for sickle cell dses
DAY 4 (3 Feb 2005)
DIAGNOSTIC PROCEDURES I.
CARDIOVASCULAR
A. ELECTROCARDIOGRAPHY – records the electrical activity of the HEART P wave – atrial depolarization QRS complex – ventricular depolarization ST - repolarization Rhythm – appearance of wave and distance Rate - N 60-100 bpm – check on # of QRS then divide it by 300 (k) ABNORMALITIES
a. atrial fibrillation – p waves “halos magkadikit. (no discernable p waves) b. atrial flutter – “saw tooth” flutter waves c. ventricular – check on QRS (N - .8-.12) ANGINA – st segment elevation, t wave inversion MI - st segment elevation or depression, t wave inversion
B. CARDIAC CATHETERIZATION -
it determine the structural abnormalities in the heart either L or R sided catheterization site: antecubital, femoral, brachial
common complications: embolism, bleeding, arrythimia “EBA” nsg mgt : monitor distal pulses (if brachial site: check @ radial if femoral site : check @ dorsalis pedis) if weak or no pulse – REPORT if (+) bleeding – report (“sandbag 10-20 lbs” – shld be at bedside)
C. STRESS TEST -
determines the ability of the heart to withstand stress equipment : threadmill & ECG nsg alert : check pulse and BP keep NPO an hr b4 the test NO Jewelries
D. CORONARY ARTERIOGRAPHY -
visualization of the bld vessels w/ contrast medium nsg alert: (+)consent check allergy to contrast medium increase oral fluid intake after to excrete dye epinephrine shld be ready for any untoward reaction
E. SWAN-GANZ CATHETERIZATION -
4 lumen for the ff CVP, Pulmonary Capillary Wedge Pressure (PCWP), Pulmonary Artery Pressure, Bld products, Balloon
CVP – measure R side pressure of the heart PCWP – L side of the heart N Pressure CVP: for R Atrium – 0-12
for SVC – 5-12 Nsg Alert : check pulse and s/s of bleeding
F. BLOOD CHEMISTRIES
SODIUM (135 – 145 meq/L) Addison’s Dses: hyponatremia (dec Na), hyperkalemia (inc K) – “FLD IMBALANCE” Cushing Syndrome: hypernatremia, hypokalemia – “FLD VOL. EXCESS”
POTASSIUM (3.5 – 5 meq/L) Hyperkalemia : Addison’s dses Hypokalemia : Cushing Syndrome Inc or dec in K PT RISK of INJURY Pt w/ digitalis & diuretics – monitor for arrhythmia
CALCIUM (4.5 – 5 meq/L or 9-10mg/dl) Hyperthyroidism – inc CA Renal Calculi Formation – inc CA @ bld
GLUCOSE (80-120) -
Higher than 140 – hyperglycemia (acidosis – may lead to ineffective breathing pattern and airway is the main problem)
-
below 50 – hypoglycemia (pt prone to injury & altered thought process)
Creatinine (.5-1.5) -
most sensitive index of kidney funx (increase BUN but N creatinine – do not report to AP)
-
increase creatinine – kidney failure or renal disorder
BUN (10-20 mg/dl) -
inc. if (+) kidney disorder
LDH (40 – 90 u/L) LDH1 – 27-37% (for heart – check for MI) LDH2 – 17-27% (for heart – check for MI) LDH3 – 8-15% (for respiratory system) LDH4 – 3-8% (for liver & kidney) LDH5 – 0-5% (for liver & kidney) LDH inc for MI for 3-4 days then it returns to N after 10-14 days
CPK or CK Male – 12-70 u/L Female - 10-55 u/L Increase CPK 3-6hrs post MI then it normalize 3-4 dyas
AST (SGOT)
SGPT (ALT)
- N 8-20 u/L - for liver (inc. for liver dses)
N 8-20 u/L more on HEART (inc for cardiac dses)
G. HEMATOLOGIC STUDIES RBC (4.5 – 5.5 million) - inc RBC – polycythemia – risk for injury – complication CVA - dec RBC – anemia – activity intolerance WBC (5-10 thousand) - to detect presence of infection, bld disorders like leukemia - dec WBC – pt prone to infection - inc WBC – hyperleukocytosis – (+) to pt w/ leukemia – risk for infxn PLATELET (150,000-450,000) - spontaneous bleeding occurs when platelet dec (pt also prone to injury) PT
PTT
APTT
(11-12 sec)
(60-70 sec)
(30-40 sec)
coumadin – check pt
heparin – PTT
monitor pt 4 bleeding
monitor pt 4 bleeding
HGB – male : 14-18 mg/dl Female : 12-16 mg/dl Dec hgb – anemia (nsg dx: activity intolerance) HCT - 35-45% - determine the adequacy of hydration and the ration of plasma to the cellular component blood inc hct
: hemoconcentration (nsg dx: fld deficit – dehydrated pt)
dec hct
: hemodilution fld excess
DOPPLER USG - to detect the patency of bld vessels – arteries & veins esp of lower extremities; - painless, non invasive, NO SMOKING 30 min-1hr b4 the test
PULSE OXIMETRY - determines the O2 saturation at blood - N 95-98 – attach to finger or earlobe (do not expose e light)
II.
RESPIRATORY
BRONCHOSCOPY – – – – – –
visualization of b. tree or airway passages; to gather specimen for biopsy; NPO b4 & after Gag reflex return after 1-2hrs; Pt may expect a sore feeling (PINK STINGED SPUTUM) Report (+) stridor CHEST X-RAY
-
to determine abnormalities of lungs and thoracic cavity; no preparation; ABSOLUTE CONTRAINDICATED TO PREGNANCY Check pt for radiation indicator Determine effectiveness of tx and whether pt is active or non-active
-
SPUTUM STUDIES to determine the gross characteristic of the sputum (refers to the amount, color, abnormal particles, consistency and characteristic) TYPE OF SPUTUM PNEUMONIA TB
- Viral – thin & watery Bacteria - rusty - blood streaked
BRONCHITIS - gelatinous CHF/ PULMONARY EDEMA - pink stinged
Sputum specimen – sterile container
THORACENTESIS - aspiration of fld at thoracic cavity (for diagnostic & therapeutic purpose)
position:
DURING – sitting AFTER - affected or unaffected side
Nsg alert:
NO COUGHING & DEEP BREATHING – during the procedure – coz this may cause puncture of the lungs; Assess for breath sounds after; Complication: bleeding and pneumothorax
PULMONARY FUNCTION TEST - thru the use of incentive spirometer - vital capacity (4-5 L of air) – refers 2 N amt of air that goes in
& out of lung after maximum inspiration. PROCEDURE:
EXHALE then INSERT mouth piece, BREATH iN, HOLD then EXHALE
LUNG SCAN - to identify the presence of blockage in the pulmonary bld vessels; - with contrast medium; - (+) consent; - assess for rxn to allergy
MANTOUX TEST - test for POSSIBLE TB EXPOSURE; - using PPD (purified chon derivatives) - angle 10-15, BEVEL UP then read 48-72hrs after 5mm in duration – (+) for HIV, multiple sex, previously (+) pt; 10mm - (+) for immigrants, children below 3yo and for pt w/ medical condition – DM & Alcoholism 15mm - (+) for general population
LUNG BIOPSY - aspiration of tissues at lungs for dx of tumors, malignancy - assess for bleeding, breath sounds & report for s/s of dyspnea
III.
NERVOUS
-
EEG shampoo hair B4 (to remove chemicals) and AFTER to remove electrode gel (shampoo or acetone) measures electrical activity of the brain (gray matter) non invasive, (-) consent detect the ff: brain tumors, space occupying lessions alcohol brain waves and seizures nursing alert:
CT SCAN
dietary modification: WITHOLD CAFFEINE – coffee and tea; WITHOLD 48hrs b4 the procedure : tranquilizers, sedatives, anti-convulsant, alcohol
MRI
PET
Use radiation to determine use electromagnetic field use gamma rays or positron electron tissue density to detect abnormality of tissue density to detect abnormality of tissue density; (detect cancer and tumor) also to detect O2 saturation @ tissue;
physiology of psychosis; and to evaluate tx give more detailed impression (ex. Measurement of blocked artery)
NSG ALERT: (w/ or w/out dye) CONTRAINDICATION
CONTRAINDICATION (same w/ ct scan BUT w/ addtl)
a.
pregnancy;
b. c. d.
obese pt (more than 300 lbs);
e.
claustrophobia (give anti-anxiety b4)
NO METAL OBJECTS - jewelries, insulin pump,
pt w/ unstable v/s (arrhythmic & HPN); pt w/ allergy to dye
pacemaker, hip replacement
“clicking sound” will be heard & lie still during the procedure lie still lie still during the procedure and “thumping sound” will be heard
-
CEREBRAL ANGIOGRAM involves visualization of bld vessels @ vein w/ the use of contrast medium. CONTRAINDICATED IN: pt w/ allergy; pregnant pt.; bleeding
Nursing Alert: a. b. c. d. e.
keep pt NPO; assess pt for allergy; monitor for signs of bldg; inc oral fld intake to excrete dye; keep epinephrine and or benadryl at bedside for emergency
LUMBAR PUNCTURE
-
aspiration of CSF for assessment to check for infection or hemorrhage position:
DURING : fetal or C-position AFTER
: FLAT to prevent spinal headache
Needle is inserted between L3 and L4 or L4 and L5 Increase fluid intake after.
CSF ANALYSIS -
Assess for the characteristic of CSF. N amount: 100-200 ml Characteristic : Clear w/ glucose, Na and H2O
like CA Tx
If REDDISH – hemorrhage If Yellowish – infection Ear licking w/ fluid – test if (+) glucose bec. CSF has glucose.
MYELOGRAM
-
test for presence of slip disc or herniated nucleus porposus (HNP).
ALERT:
Know the type of dye use: a. water based – called AMIPAQUE b. oil base – called PANTOPAQUE type of dye will determine the position of pt AFTER the procedure. If water based, the HEAD OF BED ELEVATED; If oil based, FLAT after Rationale for both oil and water based dye is TO PREVENT the upward dispersal of dye w/c can cause electrical meningitis (s/s includes: (+) seizure, headache)
IV. EENT • TONOMETRY -
to measure IOP (N 12-21) - painless but w/ local anesthesia ACUTE GLUACOMA : 50 yo and above CHRONIC GALUCOMA : 25 yo
• CALORIC STIMULATION TEST -
test the presence of Minierre’s Dses (inner ear) involves introduction of warm and cold water then NOTE FOR NYSTAGMUS – jerky lateral movement of the eye. SEVERE NYSTAGMUS – NORMAL MODERATE NYS - Minierre’s Dses NO NYSTAGMUS - Acoustic Neuroma
• GONIOSCOPY -
to differentiate OPEN and close angle galucoma;
-
non-invasive, painless
WEBER TEST
RINNE’S TEST
To determine lateralization of sound; To determine air and bone conduction If pt hears vibration better in GOOD EAR, Place tuning fork 2inches from the ear Problem would be SENSORINEURAL LOSS; place at mastoid bone or in teeth then…. if pt hear better in POOR EAR, - refers to if AIR CONDUCTION is LONGER, therefore CONDUCTIVE HEARING LOSS SENSORINEURAL HEARING LOSS; If BONE CONDUCTION IS LONGER, therefore CONDUCTIVE HEARING LOSS
V.
GASTRO INTESTINAL TRACT UPPER GI SERIES (Barium Swallow)
-
xray visualization with contrast medium - Contrast Medium: a. Gastrografin – water soluble, use straw b. Barium - swallow – milk shake like (use feeding bottle of pt) - then pt is ask to assume different positions to distribute dye @ esophagus purpose: to detect disorders of esophagus feces : “chalky-white” after: instruct pt to take laxative to excrete dye
BARIUM ENEMA (for Lower GIT) -
involve rectal installation of barium;
-
there is balloon catheter inserted @ anus then barium is instilled and pt is asked to roll-over at different position then xray is taken to detect: hemorrhoids, diverculosis, polyps and lesions;
-
after, give laxative to excrete dye (bec dye is constipating) instruct also patient to inc oral fld intake
GUAIAC TEST -
to detect the presence of bleeding and inflammatory bowel condition like CANCER;
specimen : stool
(this can be refrigerated awaiting laboratory)
AVOID the following 3 days B4 the test – bec it can yield to FALSE (+) RESULT : Red Meat, Fish and Horse Radish
CHOLANGIOGRAPHY
-
visualization of biliary tree
-
with contrast medium w/s is given thru IV
-
ALERT: assess for allergy (epinephrine/benadryl)
-
Post procedure: inc. oral fld intake –
(includes, hepatic duct & common bile duct) – same with CHOLECYSTOGRAPY – but medium given orally;
to facilitate excretion of dye
GASTRIC ANALYSIS -
analysis of gastric secretion like HYDROCHLORIC ACID Lower Level N : 2-5 meq/hr Upper Limit N: 10-20 meq/hr UPPER LIMIT YPES
a.
WITHOUT TUBE (tubeless gastric analysis)
-
using DIAGNEX BLUE (specimen: urine); if urine colors turns BLUE, therefore (+) HCL Acid; if urine (-) blue color, therefore (-) HCL Acid
b.
-
if (-) HCL Acid at stomach (achlorhydia), therefore Gastric CA;
-
if Increase HCL Acid – therefore ZOLLINGER-ELLISON SYNDROME – (+) Gastric Tumor
WITH TUBE – with the use of NGT then aspirate
ULTRASONOGRAPHY -
upper abdl USG to detect abnormalities in the upper abdl area w/ includes biliary tree and Upper GI; painless; gel at abdomen and pt is NPO
LIVER BIOPSY -
aspiration of sample tissue from the liver to detect: Hepatic CA and Cirrhosis;
-
ALERT: Check for Bleeding Time (N – 1-9 mins) and Clotting Time (N – 10-12 mins) – because liver is highly vascular organ
-
WHEN NEDDLE IS INSERTED tell pt to: Inhale then Exhale then Hold Breath – to stabilize liver position
-
Position after : R side-lying position Things to report: s/s of SHOCK – inc PR, dec BP Check v/s
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP) -
to visualize common bile duct and pancreatic duct; invasive – (+) consent;
-
NPO – tube insertion; Tell pt that tere will be feeling of soreness a wk after the procedure
COLONOSCOPY -
visualization of colon to detect: inflammatory bowel condition Chron’s Dses Diverticulitis Hemmorhoids Tumor Polyps
- (+) Consent - NPO b4 - clear liquid diet – 2days b4 the procedure position: Lateral or side lying position or L Lateral Sims
VI. ENDOCRINE
GLUCOSE TOLERANCE TEST -
ACTH STIMULATION TEST -
to detect presence of Addison’s Dses specimen: blood pt is given dose of ACTH (not nore than 40ug/dl) if still dec despite ACTH administration, therefore Adrenal Insufficiency – Addison’s Dses
DEXAMETHASONE SUPRESSION TEST -
to provide measure of bld sugar level at blood; Inform pt to have high CHO diet 2 days b4 the test; Instruct NPO a day b4 the test (npo post midnoc); Inc sugar level, therefore Diabetes
to detect endogenous depression – depression resulting thru endocrine disorder pt is given dexa then 24hr urine specimen is collected; a dose of dexa will suppress the release of adrenal hormones; if despite dexa administration still increase adrenal hormones, therefore pt is suffering depression
17 KETOSTEROID & 170 HCS -
use to detect the presence of Addison’s & Cushing’s Dses.
Addison’s – dec secretion of ketones Cushing’s – ince secretion of ketones Specimen: 24 hr urine
VANILLYLMANDELIC ACID TEST – VMA Test -
bi-product of CATHECHOLAMINE Metabolism epinephrine
norepinephrine
inc if there is TUMOR (pheocromocytoma) of Adrenal Medulla
N 2-7 mg/dl / 24hrs – if inc, therefore tumor AVOID: vanilla containing food 3 days b4 test –
ice cream, coffee, chocolates
RAIU -
pt is given iodine 131 then after 24hr followed by a thyroid scan inc indicates hyperthyroidism, dec hypothyroidism AVOID: iodine rich-food (sea foods, sea shells, sea weeds) 7-10 days b4 and to include other diagnostic procedures that uses contrast medium (“NO” - angiogram test). – bec it may yield to false (-) result. SULKOWITCH’S TEST -
detect amount of calcium excreted at urine; if to test for hypercalcemia and hyperthyroidism - gather specimen b4 meals; to test for hypocalcemia and hypothyroidism – gather after meals
VII. R E NA L
URINALYSIS -
examine the gross characteristic of the urine
urine amount : 30-60ml/hr color : clear, amber s. gravity : 1.010 – 1.025 abnormality:
lower than 1.005 – diabetic insipidus higher than 1.030 – diabetic mellitus (+) glucose – infection, DM (+) CHON - PIH, kidney dses.
Urine maybe refrigerated if waiting to be examined.
CULTURE & SENSITIVITY -
to detect infection prepare storage container
KUB -
xray of the kidneys, ureter and bladder - NO SPECIAL PREPARATION NEEDED
visualization of urinary bladder after : monitor I & O; note for s/s of bleeding
RENAL BIOPSY -
aspiration of tissues at kidney for biopsy to detect: a. malignancy/ Ca b. malignant HPN c. kidney disorder
-
note for s/s of bleeding
CYSTOURETROGRAM -
- xray of the kidneys, ureter and bladder - uses contrast medium/ dye - assess for allergy, then inc. oral fld intake after - benadryl or epinephrine at bedside for allergic rxn - NPO POST MIDNOC, cleansing enema in AM
CYSTOSCOPY -
IVP
to check the patency of the ureter and bladder; monitor I & O
CYSTOMETROGRAM -
to evaluate the sensory and motor funx of bladder; to check if bladder respond to distention after installation of flds; monitor I & O
VIII. MUSCULO-SKELETAL
ELECTROMYOGRAPHY -
to detect electrical activity of the muscle; (+) consent; to alternately contract and release the muscle as needle is inserted HOLD muscle relaxant b4 the test
ARTHROCENTESIS -
aspiration of fluids at synovial space to detect abnormalities; check for order of analgesic; apply cold pack
ARTHROSCOPY - visualization of joints - KEEP TORNIQUET, ICE PACK and ANALGESIC at bedside
BONE SCAN -
detect rate of bone destruction or bone resorption for pt w/ osteoporosis; lie still during the procedure; PAINLESS AND NON INVASIVE
IX. MISCELLANEOUS
BONE MARROW BIOPSY -
to check abnormalities at the b. marrow (eg. Leukemia) site : ILEAC REST (+) consent assess for bleeding sand bag at bedside (post procedure) – for emergency use
SCHILLING’S TEST -
specimen: 24hr urine test for VIT B12 deficiency; for pt w/ PERNICIOUS ANEMEIA; pt is given oral VIT B12 then urine is collected, then NOTE for RATE of EXCRETION of VIT B12 (N – less than 40%); eg. If 100mg Vit b was taken – 60mg shld retain at stomach and 40mg will be excreted.
URINE UROBILINOGEN to detect HEMOLYTIC DSES WITHOLD ALL MEDS – 24hrs b4 the test
BENCE-JONES PROTEIN detect presence of MULTIPLE MYELOMA (malignancy of plasma cells); RELEASED by destroyed or damage bones
ROMBERG’S TEST check FUNX of CEREBELLUM; stand erect, close eyes, and observe for inability to maintain posture Swaying, therefore TUMOR at cerebellum)
ERYTHROCYTE FRAGILITY TEST -
use to detect the rate of RBC DESTRUCTION in a hypotonic
(if pt is
solution
(RBC Lifespan: 120 days)
if lifespan of RBC >120 days, therefore HEMOLYTIC ANEMIA (EX. SICKLE CELL)
HETEROPHIL ANTIBODY TEST -
detect presence of IgM w/c is related to Epstein Virus infection
Epstein Virus Infection – causative agent of infectious mononucleousis (“kissing dses”) mgt: AVOID SHARING of utensils and glass
LYMES DSES SEROLOGY -
detect presence of BORRELIA BURGDORFERI –
causative agent of lyme’s
dses. Treatment: tetracycline
TIPS FOR DIAGNOSTIC PROCEDURE 2 moths old infant suspected of brocholitis is treated with oxygen therapy. Which result indicates that tx was effective : 02 SATURATION OF 98%.
Pt is scheduled for liver biopsy. What shld the nurse instruct pt to do during needle insertion? hold breath during the procedure upon insertion of the needle.
Staff nurse is observing a nurse caring for pt w/ cvp. W/c action of the nurse require intervention? – touching the edge of the soiled dressing using clean gloves.
Pt undergoing ERCP – important prep for nurse to make would be: keep pt NPO b4 the procedure.
Pt w/ coronary angiogram, the catheter was inserted at the L femoral artery. w/c intervention is appropriate after the procedure: palpate the popliteal and pedal pulses.
In explaining to the pt about cystoscopy the nurse shld say : the bladder lining will be visualize. A mantoux test is (+) – if the nurse assesses w/c of the following: in duration. w/c of the ff will yield an accurate reading of CVP: when the zero level of the manometer is at the level of R atrium.
w/c responses made by the pt indicates that he understands the procedure to be done in a CT scan: “a dye will be injected to me”.
A pt is to have an upper GI series – which statement shows that he understood the instruction given : “I will drink the dye”.
After liver biopsy, a potential complication: bleeding. MRI is the primary diagnostic tool for multiple scelosis bec it promotes visualization of plaques at the brain.
DAY 5 (8 Feb 2005)
PHARMACOLOGY I. GENERAL CONSIDERATIONS •
ONLY RN’s are allowed to administer (to include central line) LPN’s – peripheral IV Line route;
• • • • •
ELDERLY PT – provide with memory aid PEDIATRIC PT – do not mix w/ milk (dosage depends on wt, age and size) For SIDE EFFECTS – GI symptoms (mostly) For AD. EFFECTS – always consider bone marrow (“leukocytopenia – all PENIA”) 3 COMMON DRUGS – with patients over 65 y/o a. LITHIUM – if above 65 yo, dose shld not more than 1.0mEq b. HALDOL – if above 65 yo, dose shld not more than 6mg/day c. MEPERIDINE – if above 65 yo, shld not 50 mg
II. TRANSCULTURAL ASIANS – are stoicism attitude MIDDLE EASTERNERS -
(they refuse meds if for the 1st time)
they expect meds during first contact w/ hx care provider
JEWISH – no meds restrictions JEHOVAH’S WITNESS – do
ORIENTAL PAYLOAH (from mexico)
-
treatment for diarrhea; may cause lead toxicity
ECHINECEA - use to boost the immune system; - for pt. with cancer
ST JOHN’S WORT - anti-depressant (it funx like MAO inhibitor); - do not give to pt taking MAO
VALERIAN - sedative (used also as anti-anxiety agent) - adverse effects – GI Irritation
GINGCO BILOBA - blood thinner; - use to enhance bld circulation; - for pt w/ alzeimers - CONTRAINDICATED to pt with bleeding disorders
COMMON CONTRAINDICATIONS for HERBAL MEDS:
NO HERBAL MEDS for pregnant client; NO HERBAL to lactating pt; NO HERBAL for those with severe kidney and liver disorder
IV.
THE CHECK PRINCIPLE C– HECK-
lassification (FOR WHAT?) ow will you know that he meds if effective (evaluation) xactly what time are you going to give it lient teaching tips eys to giving it safely
Lactulose – given to pt with hepatic enceph to dec ammonia absorption - s/e : diarrhea
ANTABUSE (dizulfiram) – most appropriate time to take meds : after 12hrs of alcohol free.
COGENTIN – to prevent pseudoparkinsonism
TETRACYCLINE - can cause staining of teeth, Photosensitivity (use sunscreen when outdoors)
LITHIUM – shld have inc. fluid in the diet
(by decreasing muscle rigidity)
III. DELEGATION AND DOCUMENTATION Document all medical admin record: The following CANNOT be delegated:
time, route, dosage and untoward reaction; treatment, administration, documentation of meds
PSYCHOTROPIC I. ANTIPSYCHOTIC -
major tranquilizer; for SCHIZOPHRENIA (pt has EXCESS DOPAMINE); plays as treatment to the symptoms NOT CURE to schizo – meaning it modify the symptoms (target symptom: to decrease dopamine)
ex. Haldol Chlorpromazine Clozapine (chlozaril) Olanzapine (zyprexa) Risperdon BETS TO GIVE: after meals DOPAMINE – neurotransmitter (facilitate the transmission of neurons) In SCHIZO there in INCREASE NEUROTANSMITTER. Signs & Symptoms: a. DELUSION – “FALSE BELIEF” b. HALUCINATION - hearing sounds c. LOOSENES OF ASSOCIATION – shifting of topic CLIENT TEACHINGS:
Report ADVERSE EFFECTS of ANTI-PSYCHOTICS – which indicates agranulocytosis a. fever b. body malaise c. sore throat d. chills
hyperpyrexia and muscle rigidity -
this indicates NEUROLEPTIC MALIGNANT SYNDROME (NMS) drug of choice: Parlodel, Dantrium
Assess SIGNS and SYMPTOMS of PSEUDOPARKINSONISM a. mask-like face or expressionless face b. pill-rolling tremors c. cogwheel’s rigidity or lead pipe rigidity
AKATHESIA – “restless leg syndrome” (I feel as if I have ants in my pants) DYSTONIA Avoid direct sunlight – because meds photosensitivity Instruct pt to rise slowly – to avoid orthostatic hypotension
Check: CBC, BP, AST/ALT To prevent pseudoparkinsonism, administer ANTIPARKINSONIAN agents
IA. DOPAMINERGICS - ANTIPARKINSONIAN in schizo there is increase dopamine, therefore give antipsychotic to dec dopamine then dec dopamine causes pseudoparkinsonism. Therefore give dopaminergic.
ex.
L-Dopa Levodopa Levodopa-Carbidopa
Effective if decrease in tremors and rigidity within 2-3 days; When to give: AFTER MEALS;
Health Teachings: a. dietary modification: AVOID CHON and Vit B6 - bec it decreases drug absorption b. check for ORTHOSTATIC HYPOTENSION and PALPITATION; c. check BP and PR
IB. ANTICHOLINERGIC -
decrease ACETYLCHOLINE
ex. Benadry Cogentin
effective: if decrease tremors and rigidity; when to give: AFTER MEALS;
Health Teachings:
a. b. c. d. e. f. g.
side effects: blurred vision (no driving); dry mouth – suck on ice chips or hard candy; palpitations – check PR; constipation – inc. roughage at diet; urinary retention NOT urinary frequency decrease BP – rise slowly check BP, PR, ECG
II. ANTI-ANXIETY -
minor tranquilizer decrease Reticular Activity System – center of wakefulness
ex. Valium, diazepam, Librium, Tranxene
Effective:
Decrease Anxiety, Decrease Muscle Spasm Promote Sleep
(to pt w/ traction)
– because food delays absorption
B4 MEALS
HEALTH TEACHINGS:
a. report ADVERSE EFFECT: PARADOXICAL REACTION – opposite of side effects b. Danger of Dependency c. AVOID: Caffeine, Alcohol – it increase the depressant effect of the drug d. check RR – it causes respiratory depression e. administer VALIUM separately – because it is incompatible with any drug – use different syringe.
III. ANTI-DEPRESSANT/MANIC a. b. c. d.
TRICYCLICS MAO STIMULANTS SSRI
PATIENT with DEPRESSION – there is DECREASE norepinephrine and serotonin
A.
TRICYCLICS –
prevents the reabsorption of norepinephrine.
Ex. Tofranil, Elavil Effective:
If adequate sleep (8hrs only) Increase appetite
Best given:
AFTER MEALS
Hx Teachings:
The INITIAL EFFECT 2-3 wks after FULL THERAPEUTIC EFFCET 3-4 wks ONSET EFFECT in a WK
AVOID : juice – because an acidic medium decrease absorption of drugs REPORT PALPITATION and TACHYCARDIA and ARRYTHMIAS – adverse effects of TRICYCLICS
B.
CHECK BP and ECG
MAO INHIBITOR (MonoAmine Oxidase) -
prevents the destruction of NEUROTRANSMITTERs ex. Parnate, Nardil and Marplan
Effective
: if INCREASE SLEEP and APPETITE –
Give AFTER MEALS Hx Teachings:
AVOID – TYRAMINE CONTAINING FOOD (1 day before FIRST DOSE and 14 days AFTER LAST DOSE)
Avocado, banana, cheese (cheddar, aged and swiss)
ALLOWED: cheese – cottage and cream, FRESH MEAT, VEGETABLES
COLA, CHICKEN LIVER SOY SAUCE RED WINE PICKLES
Check BP – the drug can cause HYPERTENSIVE CRISIS – occipital headache – “my nape is aching”
2 WKS INTERVAL – when shifting ANTI DEPRESSANT – to avoid HYPERTENSIVE CRISIS ex . after MAO – 2 wks rest then can give ST JOHN’S WORT
C.
STIMULANTS (Ritalin, Dexedrine and Cylert)
-
directly stimulates the CNS. Effective:
Increase Appetite and Adequate sleep
Best to Give: AFTER MEALS -
if b4 meals, it suppresses the appetite; give NOT BEYOND 2pm bec. it causes INSOMNIA – 6 Hrs b4 bedtime; shld be given in the morning – to avoid INSOMNIA
COMPLICATIONS:
growth suppression
Hx Teachings:
D.
SSRI
provide intervals or intermittently to avoid growth suppression; check BP and PR
(selective serotonin reuptake inhibitor) Ex. ZOLOFT, Prozac
Adverse effects: s/e:
DECREASE LIBIDO and Impotence
GI
III.1 ANTIMANIC Lithium (lithane, lithobid, escalith) Tegretol Depakine/ Depakote
A. LITHIUM -
it alters level of neurotransmitters
effective if DECREASE HYPERACTIVITY give AFTER MEALS Hx Teachings:
diet: High Na (6-10 gms) and High Fluid (3-4L) N Na – 3 gms, N fluid intake 3L Basically, Lithium is a salt
Report the ff s/s (NAVDA) Nausea Anorexia Vomiting Diarrhea Abdl Cramps
-
Report also:
FINE HAND TREMORS progressing to COARSE HAND TREMORS, THIRST and ATAXIC - sign of LITHIUM TOXICITY – Dug of
choice: MANNITOL DIAMOX
Hx Teachings:
• • •
Avoid activity that increase perspiration – Na & H2o; Avoid caffeine; Monitor lithium level
(specimen: blood drawn in the morning b4 breakfast or at least 12 hrs after the last dose)
•
Frequency of Lithium monitoring: ONCE A MONTH; NORMAL LITHIUM LEVEL: ACUTE DOSE Below 65 yo Above 65 yo
MAINTENANCE DOSE
.5 – 1.5 mEq/L .6 – 1.0 mEq/L
.5 – 1.2 mEq/L .4 - .8 mEq/L
Lithium is effective with 10 – 14 DAYS before it will reach its therapeutic level.
CONTRAINDICATION OF LITHIUM: • • •
Pregnancy; Lactating; Kidney disorder
- if above s/s are (+) to patient, instead of lithium use TEGRETOL, DOPAKINE/ DEPAKOTE tegretol – a/e : alopecia dopakine/ depakote - gingivitis
ANTICONVULSANT (Tegretol and dilantin) -
for seizures, wherein there is abnormal discharge of impulse in the brain action : IT INHIBITS the seizure focus and discharge
effective: if (-) seizure given BEST AFTER MEALS –
(except for sedatives- like valium) MOST DRUGS THAT AFFECT CNS ARE BEST GIVEN AFTER MEALS TOO.
NSG ALERT: • • • • Check :
Report GINGIVITIS; Report S/S of Bone Marrow Depression – pancytopenia (dec RBC & WBC); Instruct pt to use SOFT BRISTTLED TOOTHBRUSH; Instruct pt to MASSAGE GUMS and frequent oral hygiene CBC – due to pancytopenia RBC, WBC and Platelet label
CHOLINESTERASE INHIBITORS For MYASTHENIA GRAVIS
: Prostigmin (long acting) and Tensillon
For ALZEIMER’s DSES
: Cognex (tacrine) and Aricept
(short acting)
Myasthenia Gravis – there is decrease or absence of Acethylcholine (ACTH) ACTH is a neurotransmitter the delivers the order ex. Brain to muscle to contract/move.
Therefore, the drug is given to inhibit cholinesterase in destroying ACTH (so, if dec cholinesterace and inc. ACTH, good muscle contraction)
PROSTIGMIN – long acting – for treatment TENSILLON – short acting – only for 5 mins.
– it increase muscle strength in 30 seconds (therefore, if muscle weakness disappear within 30 seconds – it is MYASTHENIA GRAVIS)
Drug Action: • • • •
Increase muscle strength (ex. Increase chewing ability or able to chew food forcefully) GIVE B4 MEALS or any activity; Meds is FOR LIFE; Report s/s of HEPATOXICITY – RUQ pain of abdomen and JAUNDICE
Antidote: ATSO4 – it reverses the effect of anticholinesterase • •
Check for LIVER FUNX TEST; Keep at bedside: endotracheal tube – for resp. problem
ANTICOAGULANT HEPARIN
COUMADIN
For ACUTE CASES of Manic Case
FOR MAINTENANCE or Chronic CASE
Antidote: PROTAMINE SO4
Antidote: VIT K
Given SubQ (Lower Abdl Fat)
Oral
LOVENOX Heparin Derivatives Antidote same w/ Heparin
Onset: 2-5 days (maintenance case) Check PT (N 11-13 sec and INR 24 sec)
Effective if (-) clot Give same time of day Report s/s of bleeding : Hemoptysis Hematemesis
HEPARIN: AVOID – green leafy vegetables – bec it is rich in Vit K and will counteract the effect of anti coagulant. Therefore, diet of patient – no appropriate. NSG ALERT: monitor PTT (N 60-70 SEC, TIL INR of 175), if more than INR - HOLD “INR” – refers to the upper limit of meds from N value to the maximum dose
COAGULATION PROCESS:
thromboplastin PRO THROMBIN
Vitamin K dependent clotting factors
COUMADIN
THROMBIN
FIBRINOGEN HEPARIN FIBRIN (CLOT)
COUMADIN – act as vit k dependent clotting factors HEPARIN –
converts PROTHROMBIN to THROMBIN and FIBRINOGEN to FIBRIN
- RAPID ACTING :onset : 24 – 48 hrs
Coumadin and Heparin – NOT to dissolve clot (only as THROMBOLYTIC – meaning it prevents ENLARGEMENT and FORMATION of CLOTS) -
can be given together
ANTIARRYTHIMICS Quinidine (quinam)
Ex.
Side notes:
Characteristics of HEART MUSCLE: a. CONDUCTIVITY – ability to propagate impulses; b. AUTOMATICITY - ability of heart to initiate contraction; c. REFRACTORINESS – ability of t heart to respond to stimulus while in the state of contraction; d. EXCITTABILITY - ability of the heart to be stimulated Inotropic effect - force of contraction or strength of myocardial contraction; Chromotropic Effect – conduction of impulses; CHRONOTROPIC Effect - rate of contraction
ANTIARRYTHMIC (quinidex, pronestyl) -
repolarization – resting phase (k goes out)
depolarization – stimulating phase (Na goes in) (therefore the depolarization and repolarization of heart muscle depends on Na and K pump.) K – once it increase or decrease, it affects the repo and depo of heart muscle which causes arrhythmia. And so, to maintain the balance in the Na and K pump give antiarrythmia because it decreases the automaticity of the heart. Antiarrythmia is effective if (-) arrhythmia; Give meds anytime;
Health teachings: a. report CNS – confusion, ataxia and headache GI - nausea, anorexia and vomiting b. RASH – therefore SKIN TEST FIRST c. REPORT s/s of QUINIDINE TOXICITY – tinnitus, hearing loss and visual disturbances d. check pt PR and ECG – waves, rate and rhythm
QUINIDINE
PROCAINE
LIDOCAINE Ventricular arrythmia
For VENTRICULLAR & ATRIAL Fibrillation
CARDIAC GLYCOSIDES -
increase force of contraction; affects the automaticity and excitability of the heart muscle; K – shld be monitored when in this meds therapy
(The heart contraction is regulated by Na and K pump. If K decreases, Calcium enters and it will result to a more increase force of contraction due to Na and Ca pump conversion.)
Effects: (+) INOTROPIC – strengthen the force of contraction (-) CHRONOTROPIC – decrease rate of contraction DIGOXIN EFFECTIVE : ACTION
DIGITOXIN
it increase FORCE OF CONTRACTION :
same
onset : 5 – 20 mins
30 mins – 2hrs
Give after meals due to GI irritation
same
CLIENT TEACHINGS:
Report s/s of TOXICITY : NAVDA
Xanthopsia –
yellowish vision or greenish halos;
Check PR – if BELOW 60/min (adult) – HOLD next dose; if BELOW 70/ min (older child) – HOLD; if BELOW 90- 110 (infants) – HOLD next dose EXCRETION Digoxin – kidney – monitor renal funx test (BUN & Crea) – report if inc;
Digitoxin – liver – AST/ ALT DIGIBIND – antidote for digoxin (lanoxin) THERAPEUTIC LEVEL:
a. Digoxin b. Digitoxin
: .5 – 2 ug/L : 14 – 26 ug/L
NITRATES (nitroglycerine) -
don’t give if pt taking VIAGRA – it will result to FETAL HYPOTENSION dilatation of coronary arteries and arterioles thereby resulting to DECREASE IN PRELOAD & AFTERLOAD.
EFFECTS:
Decrease in Preload – decrease in the amount of blood that goes to the LV; AFTERLOAD – amount of resistance offered by blood vessels that heart shld overcome when pumping blood
• • •
Effective if NEGATIVE ANGINAL PAIN; Give BEFORE any activity; Administered SUBLINGUALLY (+ burning sensation indicates drug is potent) – NO WATER because it
• • • • •
DOSES: 3 doses at 5mins interval; Report if there is persistence of pain; Check BP and PR; Keep meds in dark container (bec light dec potency); Once the bottle is open, use the meds within 3-6 mos
will dilute the meds;
DO NOT REPORT THE FF: (expected s/s) Hypotension, Headache, facial flushing “why is my face red?”
MUCOLYTICS (an antidote also for ACETAMINOPHEN TOXICITY) Ex. Mucomyst -
it decreases the viscosity of secretion; give meds anytime; client teaching: meds can be diluted w/ NSS or cola;
Side effects: NAV + Rashes
-
if no side effects, repeat dose in 1 hr
BRONCHODILATORS (ex. TERBUTALINE – brethine) -
dilates the bronchioles or airways; effective: if (-) bronchospasm; GIVEN in AM to decrease insomnia
-
REPORT THE FF: insomnia, tachycardia, palpitation-PR, + NAV
Theophylline - N 10-20; - for ACUTE ATTACK and PREVENTION of ASTMA
EXPECTORANT -
(robitussin)
stimulates productive coughing; effective : (+) COUGHING & SECRETIONS give ANYTIME; sideffects: – NAV + DIZZINESS or drowsiness – avoid activity that required alertness (ex. Driving)
ANTIBIOTICS -
bactericidal; effective: (-) infection; give ON EMPTY STOMACH – B4 MEALS; Hx teachings: REPORT rash, urticaria and “STRIDOR” – indicates airway obstruction; side effects: NAVDA + GI Irritation
I. PENICILLIN : antidote is EPINIPHRINE II. AMINOGLYCOSIDE (gentamycin) -
effective: (-) infection – give B4 meals; report the ff: OTOTOXICITY: “I hear ringing in my ear” NEPHROTOXICITY : ”oliguria” NEUROTOXICITY : “seizures”
-
check BUN, CREA (kidney funx test); check I & O (sign of nephrotoxicity) ANTINEOPLASTIC (adriamycin)
III. -
for breast and ovarian CA; effective: (-) tumor size; GIVE IN ARM – to prevent HEMMORRHAGIC CYSTITIS Hx Teachings: a. inc oral fluid intake (2-3L/day) – cytotoxic prevention; b. monitor kidney funx – I & O;
THYROID AGENTS (synthroid, cytomel) -
for HYPOTHYROIDSM; effective: if Inc in T3 and T4 and NORMAL SLEEP; pt always sleep, therefore give meds in AM – to avoid insomnia; REPORT HE FOLLOWING: insomnia, nervousness; palpitations Take meds LIFETIME (same w/ meds 4 neuro); Check HR, PR and kidney funx test;
ANTITHYROID
(PTU, LUGOL’S SOLUTION)
-
For GRAVE’S DISEASE or HYPERTHYROIDISM; Effective: Decrease in T3 and T4 (in lab data); Give round the clock;
Health Teachings:
a.
Report sore throat, fever, chills, body malaise because meds cause AGRANULOCUYTOSIS; b. Report lethargy, bradycardia, and INCREASE SLEEP – indicates that pt is having HYPERTHYROIDISM; c. Diarrhea with metallic taste – sign of IODINE TOXICITY
ANTIDIABETICS -
(INSULIN)
effective: N Blood sugar (80-120) for DM Type 1 (insulin dependent); give in AM b4 meals; check: a. instruct S/S OF HYPOGLYCEMIA – dizziness/ drowsiness difficulty in problem solving decrease level of consciouness cold clammy skin b. monitor the blood sugar level in early AM and supper time
INJECT AIR FIRST to NPH then inject air and WITHDRAW FIRST with REGULAR.
PEAK OF ACTION (refers to – when patient becomes HYPOGLYCEMIA) REGUALR INSULIN - lunch time Intermediate - late in the afternoon – B4 dinner Long Acting - B4 Breakfast
SULFONYLUREAS -
for DM type 2; stimulate pancreas to produce insulin; effective – N bld sugar level; give b4 meals regularly; teachings: a. s/s of hypoglycemia; b. monitor renal funx test; c. antidote for hypoglycemia – ORANGE JUICE
ANTACIDS -
(Orinase)
(amphogel, tagamet)
ALUMINUM HYDROXIDE GEL – antacid and it also dec phosphate level in pt renal failure; Effective: dec phosphate (-) pain give on EMPTY STOMACH (1 hr b4 or 2hrs after meals); instruct pt to REPORT: muscle weakness in lower extremities – indicates HYPOPHOSPATHEMIA administer with glass of water; check phosphate level and renal funx test; assess for constipation
LAXATIVES (dulcolax) Colace Metamucil Dulcolax Lactulose -
– stool softener - bulk forming - rapid acting - 15-30 mins
effective : (+) BM; give AT HS (if NOT diagnostic procedure); give AFTER MEALS –for dyspepsia; meds is given in short duration only because of dependency teachings: a. b. c. d. e.
be near or stay near CR; s/e: diarrhea; NO lactulose for pt w/ diarrhea; Causes hypokalemia – therefore check electrolytes Increase fld intake – to avoid dehydration
DIURETICS Target Organs a. Diamox – exerts effect at Proximal Convuluted Tubules; b. Lasix – at Loop of Henle; c. Diuril – at Distant Con. Tubules LOOP DIURETICS (lasix) - effetctive: incrase urine output; - give in morning to prevent nocturia; - teachings: a. monitor for hypokalemia level and I & O; b. report muscle weakness; c. give K rich food – banana, orange THIAZIDE (diuril) -
give in AM; monitor for hypokalemia; check I & O, K level, PR and BP
K-SPARRING (triamterene, aldactone) -
effective: inc. urine output; give in AM; teachings: monitor for HYPERKALEMIA check PR and K
ANTIGOUT
PROBENECID
COLCHICINE
ALLOPURINOL
- URICOSURIC - for ACUTE GOUT - for CHRONIC GOUT - promotes excretion of uric acid - has anti-inflammatory effect by - prevents or dec formation preventing deposition of u.acid of u. acid @ joints - s/effects: NAV + - NAV + Bldg and Bruising - dizziness/drowsiness Hypersensitivity agranulocytosis (check CBC) - ONSET: 8-12 wks
- ONSET: 1-3 wks
TEACHINGS: a. Increase ORAL FLUID INTAKE; b. Monitor uric acid levels;
MIOTICS (timoptic, piloca) -
DECREASE IOP (N12-21) for pt w/ glaucoma; Give ANYTIME – but for LIFETIME; Teachings: a. it causes blurring of vision and brow pain; b. administer meds at lower conjunctival sac; c. press the inner canthus for 1-2 mins to prevent systemic side effects (hyperglycemia and hypotension)
MYDRIATRIC -
(AK-Dilate)
effective: pupillary dilatation; give ANYTIME (but if pt for surgery, give b4); teachings: may cause blurring of vision lower conjuctival sac
CARBONIC ANHYDRASE INHIBITORS (diamox) -
for GALAUCOMA – lifetime; to decrease production of acqueous humor; effective: N IOP and Inc. urine output; effective to pt with MENIERE’S DSES – dec vertigo teachings: a. check urine output; b. report: s/s of dehydration bec of diuretic effect c. blurred vision d. monitor I & O and IOP
ANTI-ACNE (acutane, retin-a) -
decrease sebaceous gland size; given in AM to prevent insomnia; avoid sunlight: photosensitivity pregnancy: fetotoxic - therefore check if pt is pregnant; check if pt has skin irritation – may burn the skin
TOCOLYTICS (Yutopar, MgSO4) -
relax the uterus; drug of choice for pre-term labor; effective: (-) pre-term or relaxed uterus;
-
give: ORAL – B4 meals and IV – anytime; teachings: a. signs of Ca Intoxication: hypotension, hypothermia and hypocalcemia b. check bld pressure; urine output (N 30ml/hr) c. check RR – at least 12/min d. check patellar reflex – shld be (+) knee jerk
HOLD if RR – 10/min and urine output: 15ml/hr Antidote: Calcium Gluconate
OXYTOXIC PITOCIN
METHERGIN
To induce labor To prevent post partum hemorrhage Effective: Firm and Contracted Uterus Give anytime If IV, use “piggy back” Teachings: a. REPORT the ff: HYPOTENSION (due to inactivation of ANS – neurological effect of drug); b. Headache c. Hypertension (cardiovascular effect of the drug) d. Check BP, Uterine Contraction – especially the duration – N 30-90 sec - report if beyond 90 sec – sign of uterine hypertonicity e. Check Force, Duration and Frequency of Uterine Contraction
PROSTAGLANDIN (cytotec, E2gel) -
anti ulcer drug to dec gastric acidity; decrease ripening of the cervix w/c leads to effacement then dilatation then abortion; give after meals; assess for diarrhea and gastric irritation; check for pregnancy bec it may cause abortion
TIPS ON PHARMACOLOGY Patient receiving DIAZEPAM, the nurse notice that there is no change in patient behavior. What shld the nurse do? – VERIFY THE PT DIET
COGNEX – given with AZEIMERS’S DSES – to increase mental functioning
Pt w/ PVC : bedside : XYLOCAINE
Pt w/ COMPLETE HEART BLOCK: give ATSO4 – it increases HR
Pt w/ DIVERTICULITIS (pt has diarrhea) – the ff meds were given: what meds the nurse shld question : LACTULOSE
Morphine S04 given to pt with Pul. Edema – to decrease anxiety
Pt ask the nurse on why she will take COUMADIN when shes already taking HEPARIN – Heparin is given for ACUTE CASES while Coumadin for maintenance
Pt on CHEMOTHERAPY complains of nausea and vomiting, w/c meds can be given – ZOFRAN
Expected side effects of STEROIDS : wt gain, obesity and Inc appetite
Pt is taking LEVODOPA – observe for URINARY RETENTION
ADREAMYCIN – causes hemorrhagic cystitis
DESMOPRESSIN ACETATE – administered INTRANASALLY
FESO4 – shld be given w/ orange juice
ASPIRIN I s given to pt w/ TIA – to decrease platelet aggregation
Pt taking ANCEF – observe for skin rashes
Pt to receive NPH at 7:30am, the nurse shld expect for hypoglycemia – LATE in the AFTERNOON
TYPES OF PRECAUTION
AIDS
(universal)
DIARRHEA
(enteric)
HEPA
A
H
GL
GW
M
x
yes
yes
yes
yes
x
yes
(enteric)
x
yes
yes
x
yes
x
x
x
B
(universal)
x
yes
yes
yes
yes
C
(universal)
x
yes
yes
yes
yes
MRSA
(contacts)
yes
MENINGITIS/SEPTIC SCABIES TB
P
(contact)
(tb Precaution)
PEDICULOSIS
(contact)
P – private room H – handwashing GL - gloves GW – gown M - mask AIDS – universal Norwalk Virus – respiratory Hepa A – contact MRSA – contact Scabies – contact
(enteric)
x
yes yes
yes
yes
yes
yes
x
x
yes
yes
x
yes
yes
yes
yes
yes
yes
yes
yes
x
yes
yes
yes
Day 6 (Feb 9, 05)
D.I.S.E.A.S.E.S (MEDICAL-SURGICAL NURSING) GENERAL CONSIDERATION • •
Priority: Oxygenation The disorders result as alteration in the function of HEART (pump), BLOOD (transport mechanism of oxygen, nutrients, hormones & CO2) and BLOOD VESSELS (passageway).
PEDIATRIC CONSIDERATION a. all factors necessary for appropriate cardiovascular functioning are present at birth EXCEPT VIT. K (w/c is produced by intestinal mucosa); b. there are structures which are present at birth that may alter the route of blood circulation (present at birth: foramen ovale, ductus arteriosus, ductus venosus) c. note the CARDIAC RATE of pediatric pt
(minimum $ y. children – 90-110, older c. – 70)
REPORTABLE S/S FOR ADULT • •
Palpitation, Pain and Paroxysmal Nocturnal Dyspnea For pediatric patient: observe for PALLOR – if (+) indicates ANEMIA for baby Nocturnal dyspnea – diff. of breathing at night Paroxysmal ND – when pt feels as if he’s drowning
HEART SOUNDS:
S1 - normal – “lubb” S2 - -do- “dub” -
in assessing S1 & S2 use BELL of steth
S3 - N for Pediatric pt
(ABNORMAL for adult pt – it indicates CHF or Aortic Stenosis)
Steth - BELL – for LOW PITCH SOUND (ex. Murmur) Diaphragm – for HIGH PITCH SOUND
SHOCK mp: decrease in circulating blood volume TYPES
CARDIOGENIC – pump failure (CHF, MI, Atherosclerosis Heart Dses, Mitral Valve Dses) HYPOVOLEMIC - related to fluid loss (pt w/ open wound, traumatic injury, burn) ANAPHYLACTIC - cause by allergic reaction (laB procedure w/ dye, asthma, poison) NEUROGENIC - caused by vasomotor collapse (vasomotor – located @ medulla oblongata w/c is responsible for dilatation & constriction of bld vessels)
SEPTIC – due to systemic infection
(ex. Septicemia)
TRIAD SYMPTOMS OF SHOCK a. Altered level of consciousness b. Hypotension; c. Tachycardia and Tachypnea
(dec bld circulation – result to dec o2 in the brain);
Patient in shock- there is also (+) pallor and (+) oliguria – due to dec bld circulation & narrowing of bld vessels Lab Data (to check bld volume circulation) – check HEMATOCRIT (N-35-45%) - check Urine Output - check CVP Nsg Dx: FLD VOLUME DEFICIT rel to dec in Circ Vol. Priority Intervention: Fld replacement
(D5Lr, NSS. Bld Trans – for jehova’s use plasma expander)
ANEMIA MP: Decrease RBC due to decrease production or increase destruction Risk Factors: Age Gender Surgery Secondary to existing medical condition (ex. Renal Failure) Kidney – produce erythropoiten that stimulates bone marrow to produce RBC
TYPES:
a. b. c. d. e. f.
Iron Deficiency Anemia (IDA) Pernicious Anemia (PA) Folic Acid Deficiency Anemia (FADA) Sickle Cell Anemia (SCA) Aplastic/ Fanconis Anemia (AA) Talasemia Anemia (TA)
IRON DEFICIENCY ANEMIA -
common in infants and children; characteristic of patient: chubby but pale they are also called “milk babies” those baby 5 yo but still taking milk (milk are poor source of iron)
MP: Nutritional Deficiency S/S : Fatigue Fainting Forgetfulness Pallor, cold clammy skin Dyspnea (due to dec RBC) Lab data: Decrease in HgB (N male: 14-18, Female: 12-16) Characteristic of RBC: HYPOCHROMIC & MICROCYTIC
Nsg Dx: Activity Intolerance Priority Intervention: a. Correct the deficiency – by administering iron supplements, - IRON RDA – 15-30 mgs/ day eg.
Oral FeSO4 (take w/ orange juice) if ELIXIR – use straw to avoid staining of teeth if IM (inferon) – “Z” track method (for Z track IM – PULL SKIN LATERALLY, deep IM, wait 10 seconds before pulling the needle)
FeSO4 – evaluate AFTER 4 weeks to check the effect b. Diet: iron rich food – (organ meat, dried foods, “egg yolk” – iron, “egg white” – CHON); c. provide patient with BED REST – due to fatigue
PERNICIOUS ANEMIA -
common in elderly; common in POST GATRIC SURGERY
Main Problem: Lack of INTRINSIC FACTOR at the stomach (intrinsic factor – the one that absorb vit b12)
In elderly, there is that GASTRIC ATROPHY w/c leads to dec in the Intrinsic factor S/S:
3F (fatigue, fainting, forgetfulness) Beefy Red Tongue or glossitis Peripheral Neuropathy (tingling sensation at lower extremities – usually both legs are affected)
Lab Data: a. check Hgb b. SCHILLING’S TEST (24hr urine) c. RBC characteristic : MACROCYTIC & HYPERCHROMIC Nsg Dx: Activity Intolerance Risk for Injury due to p. neuropathy Priority Intervention: a. Correct the deficiency – give Vit B12 b. Bed rest – due to fatigue
(IM, Once a month for lifetime);
FOLIC ACID DEFICIENCY ANEMIA -
common in infants, adolescents, pregnant, lactating and overcooked food;
Main Problem: Deficiency in Folic Acid or VIT B9 or FOLACIN S/S: all symptoms of pernicious anemia EXCEPT P. NEUROPATHY Lab Data: HgB Folic Acid level (N 4mg/day) – green leafy veg. (spinach) Nsg Dx: Activity Intolerance PI:
(NO RISK FOR INJURY coz NO P. NEUROPATHY)
Inc. folic acid in the diet – g. leafy; Bed Rest
SICKLE CELL ANEMIA -
autosomal recessive hereditary presence of “S or C” shape Hgb due to dec O2
STATUS
N
1 PARENT W/ TRAIT BOTH PARENTS w/ TRAIT I parent TRAIT, 1 DSES BOTH parents w/ Disease
TRAIT TRANS 50% 25%
DSES TRANS
50% 50% 0
0
(SICKLING OF RBC)
0 25% 50%
0
50% 100%
Risk Factors: Dehydration (dec in circ bld volume – result in sickling of RBC); Infections Conditions that lead to SHOCK S/S: 3Fs + Fever
(due to dehydration)
+ Pain + Jaundice Hepatomegally
Complications: a. Vasocclusive Crisis (hallmark of the dses) - bld vessels obstruction by rigid and tangled cells w/c causes tissue anoxia and possible necrosis
b. Spleenic Sequestration Crisis c. Aplastic/ Megaloblastic Crisis –
– massive entrapment of red cells in the spleen & liver
bone marrow depression w/c resulted to DEC RBC, WBC & PLATELET
Lab Data: Sickledex Test (+) Turbid Solution Nsg Dx:
PI:
Activity Intolerance Fld Volume Deficit Pain – due to vasocclusive crisis
Hydration and relief of pain (inc oral fld intake) Prevent dehydration Meds for Pain – Morphine SO4, acetaminophen Since HEREDITARY – refer to geniticist
APLASTIC ANEMIA MP: Hereditary (there is DECREASE IN RBC, WBC & PLATELET) Autosomal Recessive S/S: 3Fs + Pallor + Dyspnea Risk for Infection (dec in RBC) Bleeding (dec in Platelet) Lab Data: HgB, CBC, Clotting Factors Platelet, Bleeding & Clotting time Nsg Dx: PI:
Activity Intolerance (dec in RBC) Risk for Injury (dec in WBC and Platelet)
Bld transfusion; Reverse Isolation; Genetic Counseling; Bed rest
THALASEMIA Risk Factors: Common in Blacks, Italian, Greeks, Chinese, Indians MP: Hereditary Autosomal Dominant – common in female and male There is a defect in polypeptide Chain of HgB – ALPA and ETA Chain – there is RBC destruction
Types: a. Minor Thalasemia Anemia – mild anemia: 3Fs
b. Intermedia TA – more severe anemia + Speenomegally Jaundice (inc deposition of iron @ tissue) Hemosidorosis c. Major TA – severe anemia + Spleenomegally Lab Data: HgB Clotting and Bleeding Time Nsg Dx:
Activity Intolerance Risk for Injury
PI :
Bld Transfusion, IVF Dietary supplements of Folic Acid and Iron Surgery (last resort)
LEUKEMIA MP: proliferation of immature WBC Characterized by Remission and Exacerbation Types: a. LYMPHOCYTIC – common in young children (proliferation of lymphocytes) b. MYELOGENOUS – adolescent and adult (proliferation of granulocytes) TRAID S/S: • • •
Anemia (initial) + 3Fs Bleeding Infection
Lab Data: WBC – hyperleukocytosis (150 – 500,000K) – expected NDx:
PI:
Risk for Injury Activity Intolerance Risk for infection Bed rest Avoid Contact Sports Reverse Isolation Blood transfusion Bone marrow transplant
IDIOPATHIC THROMBOCYTOPENIC PURPURA (ITP) or WERLHOF’S DSES -
common in BLACKS; cause: idiopathic
unknown (viral and autoimmune) s/s:
petechiae ecchymosis hemorrhage (all signs of bleeding)
lab data: Platelet Count of less than 20,000
(spontaneous bldg)
(N 150,000 – 450,000)
Nsg Dx: Risk for Injury Fld Vol. Deficit PI :
(due to bldg)
SAFETY –prevent bleeding Give pt platelet, IVF and Bld Transfusion Corticosteroids – “wonder drugs”
HEMOPHILIA -
inherited – bldg disorder
TYPES: a. Hemo. A - deficiency in factor 8 b. Hemo. B - deficiency in Factor 9 c. Von Willebrand’s Dses – common in male and female HEMPPHILIA A and B - Autosomal Recessive Link
(from mother to male)
Von W Dses - Autosomal Dominant – Mother and Father S/S: Hemarthrosis – Hematoma Hematuria Hematemesis
bldg between joints that usually affects ankle, knee and elbow joints;
(above mentioned are signs of HEMORRHAGE)
Lab Data : PROLONGED CLOTTING TIME Nsg Dx : Risk for Injury PI : SAFETY then RICE
(REST, IMMOBILIZE, COLD COMPRESS, ELEVATE)
For JEHOVAH’S – use plasma expander (cryoprecipitate) instead
TIPS FOR BLOOD DISORDERS
If all of the ff data were obtained by the nurse, w/c one is MOST SUGGESTIVE of CARDIOGENIC SHOCK - Inc. HRate from 84 to 122 bpm;
The nurse admitted a 4 yo child with SICKLE CELL DSES – the priority for the patient is – HYDRATION;
w/c of the ff is TYPICAL for patient w/ ANEMIA - SHORTNESS OF BREATH ON EXERTION;
common manifestation of LYMPHOCYTIC LEUKEMIA is – PETECHIAE;
a mother of 15 mos old child with IDA makes the ff comment. w/c one is related to child condition - “MY CHILD DRINKS 2 QUARTS OF MILK/DAY”;
a 7 yo boy with HEMOPHILIA was admitted. MANIFESTATION – HEMARTHROSIS;
pt w/ IDA has NSG DX of ALTERED NUTRITION LESS THAN BODY REQUIREMENTS. w/c of the ff shld the nurse instruct the pt to do - INCLUDE VEGS. AND MEAT in your diet at least 1 meal a day;
w/c of the ff is the priority intervention for pt w/ IDA – PROVIDE BED REST ALTERNATING w/ activities;
w/c of the ff is indicative of thrombocytopenia - HEMATURIA
w/c of the ff is EXPECTED
CARDIOVASCULAR PEDIATRICS FETAL CIRCULATION 3 FETAL STRUCTRUES
PLACENTA
UMBILICAL VEIN
UMBILICAL ARTERIES
DUCTUS VENUSUS (functionally, closes at birth)
Vena Cava
Right Atrium AORTA
FORAMEN OVALE (functionally, closes at birth)
R Ventricle
L VENTRICLE
L ATRIUM
LIVER
LA
LV
LUNGS
DUCTUS ARTERIOSUS (functionally closes by 3-4 days at birth) AORTA
P. ARTERY
Therefore, if these 3 fetal structures will not close, CONGENITAL HEART DISEASE
CONGENITAL HEART DISEASE ACYANOTIC HEART DSES
Dec Pulmonary Bld flow
Obstructive CHD
CYANOTIC HEART DISEASE
Decrease Pulmonary
Vent. Septal Defect (most common) Atrial Septal Defect Patent Ductus Arteriosus
Pulmonary Stenosis Aortic Stenosis Coarctation of the Aorta
Tetralogy of Fallot (most common) Transposition of the Great Vein Truncus Arteriosus Tricuspid Atresia
Usually due to: -
Maternal Infection – measles, c. pox Age 40 and above Medical Conditions – DM Alcoholism
Signs and Symptoms:
Difficulty feeding Retarded Growth Tachypnea/Tachycardia Frequent URTI ANS – brow seating
Complication: CH Failure
(check for “murmur”)
CVA
(due to plycythemia – Inc RBC)
Lab Data: 2 D Echo Nsg Dx: Altered Tissue Perfusion PI : Oxygenation Surgery If < 2yrs old prepare the patient the moment the diagnosis was confirmed/ determined; For 2-7 yrs old – surgery is equal to child age ( ex 3yo, therefore prepare the child 3 days prior to surgery) If > 7yo – parents decision
PATENT DUCTUS ARTERIOSUS -
connection problem : P Artery and Aorta “machinery-like murmur” (+) brow seating (+) retarded growth (+) tachycardia/ tachypnea
LAB DATA : 2 D-Echo CVP
PExam Nsg Dx : Altered Tissue Perfusion PI :
Oxygenation INDOMETHACIN
ACYANOTIC POSITION: ORTHOPNEIC (position for CHF) then SURGERY
TETRALOGY OF FALLOT -
pulmonary stenosis, coarctation of aorta, right vent. Hypertrophy, vent septal defect “boot-shape heart” tet spell – squatting w/ cyanosis
LAB DATA : 2 D-echo Complication : CVA – check for RBC Count Nsg Dx : Risk for Injury PI :
Oxygenation Position the Pt. : SQUATTING Surgery
COARCTATION OF AORTA -
Higher BP in the Upper Extremities and Lower BP in the Lower Ext.
Lab Data : BP, 2 D-Echo PI :
Oxygenation Position the patient: Orthopneic or semi – fowler’s position
KAWASAKI’S DISEASE -
due to acute vasculitis (inflammation of bld vessels) of the heart; especially to JAPANESE children and toddler 5yo and below
S/S : High Spiking Fever for 5 Days Lymphadenopathy Strawberry Tongue Palmar and Feet Desquamation
Lab Data :
No Specific Diagnostic test Check ECG
Nsg Dx :
Altered Tissue Perfusion Altered Thermoregulation Altered Skin Integrity
Diet :
High CHON
TIPS FOR CARDIOVASCULAR – PEDIA
w/ of the ff is an OUTSTANDING SYMPTOM OF CARDIOVASCULAR PROBLEM in children – difficulty in feeding;
w/c of the ff is an appropriate intervention for a child who keeps on squatting because of Tetralogy of Fallot - if LESS THAN 1 yo – flex lower extremities towards the abodomen;
a child who was brought in to a well baby clinic turns cyanotic while crying – REFER to the physician;
the BLD VESSELS INVOLVE in PATENT DUCTUS ARTERIOSUS – pulmonary artery and aorta;
w/c of the ff data in mother health history indicates a risk factor for congenital heart disease – ADVANCE AGE;
when admitting a pt w/ suspected congenital heart disease, w/c intervention is priority – decreasing the metabolic demand of the heart
CORONARY ARTERY DISEASE (CAD) Main Problem :
NARROWING and OBSTRUCTION of Coronary Arteries which could lead to HYPOXIA – reversible (which could further progress to ANGINA) and or ISCHEMIA – irreversible (that could progress also to dev’t. of SCAR FORMATION that can lead to MI).
Risk Factors:
Family History Atherosclerosis Smoking Elevated Cholesterol HPN
Obesity Physical Inactivity Stress
CAD
HYPOXIA
ISCHEMIA NECROSIS
ANGINA Myocardial Infarction – “ jaw pain”
this leads to decrease O2 – and will result to the conversion of aerobic metabolism to anerobic thereby resulting to the production of LACTIC ACID – that will stimulate the nerve ending of the heart w/ will produce/ result to PAIN that is precipitated by: EATING Elimination – due to valsalva manuever Exercise/effort/ exertion Emotion Extreme Temperature – “cool temp” – vasoconstriction sEx
PAIN MTOCARDIAL INFACRTION • • • •
Precipitated by 6E’s Pain that resembles “indigestion”, crushing, excruxiating Pain radiates to the L Jaw, L arm, L shoulder Relieved by SO4 Opiods (MORPHINE)
Pain confined at sternal area Pain that resembles “pressure”
•
Pain occurs AFTER MEAL (post cebum) or AFTER ACTIVITY
SAME
•
•
ANGINA
S/S of above mentioned + SHOCK s/s – esp to CARDIOGENIC SHOCK w/c is due to PUMP Failure – that leads to dec cardiac Output that leads further to CHF.
ECG – initial change is ST SEGMENT DEPRESSION w/
SAME
Relieved by rest & NITROGLYCERIN
T WAVE INVERSION Increase CHOLESTEROL SAME HDL – “good” or Healthy – liver for metabolism – 30-80 LDL - “bad” – peripheral vascular system – bld vessels- 60-80 CARDIAC ENZYMES #1 Myoglobin Troponin CK – within 2-3 days LDH 1&2 – within 10-14 days
•
SAME
Nsg Dx : PAIN Altered Tissue Perfusion Impaired Gas Exchange
• Priority : Airway (Oxygenation) •
Goal of CARE a. To decrease oxygen metabolic demand - position : SEMI-FOWLER’S - administer O2 as ordered - administer meds: MI : Morphine SO4 – monitor RR, effective : (-) pain, ANTIDOTE : Naloxone HCL – Narcan ANGINA : Nitroglycerine – dark container give b4 activity maximum of 3 doses, 5 mins interval effective: tingling sensation, sublingual provide rest – due to pain b. Diet : Low Na and Low Cholesterol
HEALTH TEACHINGS:
Identify types of Angina: Stable Angina – predictable – angina that occurs w/ activity; Unpredictable – relieved by Nitroglycerin; Variant/ Prinzmetal – severe form of Angina; Nocturnal Angina – occurs at night; Decubitus Angina – when pt is lying down Intractable Angina – unresponsive to tx Post MI Angina
For patient with MI – focus on complications :
a. PVC or PVBeats – defibrillation/ cardioversion b. Ventricullar Fibrillation – Lidocaine – s/e “rashes”
CARDIOVERSION
DEFIBRILLATION
- synchronize - esp. for VTACH w/ PULSE
- unsynchronized - for VTACH w/o PULSE
SEX – for pt w/ MI – resume if pt tolerate 2-3 plights of stair w/o pain; - take meds b4 sex; - position during sex : passive – let the girl do her share
ACTIVITY – advised pt to have frequent rest period; DIET : avoid PROCESSED FOODS; MILK Salty Sea Foods Pastries – esp. yellow cake
FOR ANGINA APIN – instruct patient to report pain that last more than 2o minutes (indicative of MI);
Weak or absent PULSE – indicative of VENTRICULLAR FIBRILLATION
Report NECK VEIN DISTENTION – indicative of CHF complication
Report BLEEDINGs – especially to pt on THROMBOLYTICS – t-PA and Streptokinase
CONGESTIVE HEART FAILURE main problem : PUMP FAILURE – inability of the heart to pump an adequate amount of blood to meet the metabolic demands of the body how will the heart compensate?
The HEART will pump harder- Inc HR (tachycardia) – that will result to enlargement of the heart muscle (hypertrophy) – w/c can lead to dilatation and congestion of the cardiac muscles - thereby resulting to decrease in the cardiac output.
PUMP FAILURE EFFECTS:
Backward Effects : backflow of blood – systemic congestion; Forward Effects : decrease cardiac output – dec in tissue O2 perfusion – that leads to overwork respiratory system
LEFT HEART FAILURE – early signs of CHF Therefore, Right Heart Failure – will be the late signs of CHF as complication of LHF Risk Factors to Heart Failure:
- Arrythmias - Coronary Dses & HPN - Renal Failure LEFT SIDED HF – dyspnea and other “pulmonary s/s” – “crackles”
RIGHT SIDED HF – systemic effect –
distended jugular vein Ankle edema Ascites Hepatomegally
LEFTS SIDED HF Lab Data :
RIGHT SIDED HF
Swan Ganz PAP (N 20-30) PCWP (N 8-13)
CVP (N R – 0-12, V Cava – 5-12)
X-ray
X-ray
Nsg Dx :
Altered Tissue Perfusion Ineffective Breathing Pattern – for LHF Fld Volume Excess – for RHF
PRIORITY :
Oxygenation Position: Semi-Fowler’s Administer: Digoxin – absorb in GI Vasodilators Diuretics Morphine – for CHF – it causes pheriperal vasodilation by Decreasing the amount blood going back to the heart.
DIET : LOW Na – NO PMS HEALTH TEACHINGS : a. Activity – rest b. dietary counseling – NO PMS c. report s/s of complications DIGITALIS – D. Toxicity: yellow vision; Muscle weakness (hypokalemia) – that can lead to arrythmia Dyspnea – s/s of pulmonary edema;
HYPERTENSION MP : blood pressure higher than 140/90 (hypertensive state)
PREGNANCY INDUCED HPN Elevation of BP that occurs after 20-24 (5 mos- age of viability) wks of gestation
pre hypertensive phase
120/80, therefore N BP : 110/70 Risk Factors:
Common in BLACKS; Obesity Stress Smoking
if BP elevated B4 20-24 wks & cont after delivery – CHRONIC HPN Levels of PIH
a. HYPERTENSIVE DISORDER OF PREGNANCY - INC. BP + EDEMA & Proteinuria (s/s of PRE-ECLAMPSIA)
b. PRE-ECLAMPSIA S/S + convulsion, Abdl pain & Headache PHASE c. ECLAMPSIA + Bleeding = HELP SYNDROME
TYPES:
- ECLAMPSIA
a. b. c. d.
ESSENTIAL HPN – cause – unknown BENIGN – usually of long duration, onset is CHRONIC MALIGNANT – acute or abrupt onset, short in duration SECONDARY – related to existing medical condition
HPN IN PREGNANCY – usually related to generalized spasm of the arteries
PRE-ECLAMPSIA TYPES: a. MILD b. SEVERE
BP 140/90, PROTENURIA is <5mg/hr (N - .5-1GM) BP 160/90, PROTENURIA is >5mg/hr
HEADACHE and ABDOMINAL PAIN – s/s of ECLAMPSIA, indicative of impending convulsion.
ECLAMPSIA + BLEEDING = HELP SYNDROME H – emolysis E – levated Liver Enzyme L – ow P- latelet (All are signs of bleeding) S/S of HPN:
-
Headache Retinal Hemorrhage Edema above s/s can further lead to complications: Coronary artery dses CHF Chronic Renal Failure CVA
LAB DATA: Blood Pressure Elevated Cholesterol For PIH : (+) Proteinuria, Inc BP and Inc Cholesterol Nsg Dx:
Altered Health Maintenance Risk for Injury
PIORITY:
Stabilize BP
How? I. Non-Pharmacologic Features Stress Management Deep breathing Diet : Low Na/ Cholesterol Position : if inc BP – supine position
II. PHARMACOLOGIC MEASURES
Antihypertensive Diuretics Aspirin Antilipimic - simvastatin & lovastatin – give after meal nighttime Monitor liver Funx test – meds above are hepatotoxic
Pts w/ PIH meds: a. MgSo4 – antidote is CAgluconate b. Darkened room – to dec stimulus thereby preventing convulsion
PERIPHERAL VASCULAR DISEASE Arterial Obstruction Color pallor Edema (-) or mild Nails brittle nails Pain intermittent claudication Pulse (-) Temperature cold Ulcer dry & necrotic
Venous Obstruction ruddy (+) & severe N homan’s sign (+) warm wet
(pain @ gastrocnemeus area)
TYPES: BURGER’S DSES
RAYNAUDS
ARTERIOSCLEROSIS OBLITERANS
FEMALE
MALE
(THROMBO ANGITIS OBLITERANS) common
:
MALE
AREA AFFECTED :
MP :
Lower Ext.
Upper Ext – 97% 3% - lower ext
Upper & Lower Ext
Affects arteries and veins
Arteries ONLY
Arteries ONLY
“Angitis” – inflam. of Spasm of Arteries Arteries & veins of lower ext of Upper & lower ACUTE
S/S:
INTERMITTENT CHRONIC - (+) pain usually related to - (+) pain that narrowing of blood vessels. accompanied by color changes: PALLOR that progresses to CYANOSIS then REDNESS & aggravated by exposure to cold – NO SHOVELING OF SNOW & COLD BATH & exposure to cold – wear gloves
Outstanding s/s is INTERMITTENT CLAUDICATION – pain that worsens w/ activity or pain that is relieved by rest. - aggravated by smoking – causes further narrowing of bld vessels
LAB DATA : Inc Nsg Dx:
PI : MEDS :
WBC & ESR
DOPPLER USG
Altered Tissue Perfusion same Pain -do-
Relief of Pain
-do-
Inc Cholesterol and Ca
same -do-
-do-
(for all types)
DIET :
Hardening of arteries due to fatty deposits
Anticoagulants Vasodilators (papaverin – pavabid) Antihypertensive
Low Cholesterol
VARICOSE VEIN
THROBOPHLEBITIS
PHLEBOTHROMBOSIS
weakening of venous valves; CLOT + Inflammation job related (prolong sitting/standing) pregnancy hereditary secondary to existing medical condition
Clot
s/s : dilated tortous vein dragging sensation “heaviness” edema (unilateral/ bilateral) – tape measure to monitor leg circumference Pain Lab data:
1. conservative test – TRENDELENBURG TEST – pt lie down, elevate/ raise the legs then stand up and observe for bulging of vein; 2. DOPPLER USG Nsg Dx :
PAIN Altered Tissue Perfusion
Hx Teachings :
• • •
• • •
Elevate the legs above the heart; Use support stockings; Surgery – vein ligation & stripping Sclero therapy – injection of sclerosing agents to make wall stronger thereby preventing veins to bulge.
NO MASSAGE – coz it may dislodge the clots; KNEE HIGH STOCKINGS; COLD COMPRESS
ABDOMINAL AORTIC ANEURYSM (AAA) - weakening of portion of abdl aorta – leading to dilation; - could be related to aging and HPN TYPES: Fusiform - entire wall is affected Dissecting - part of inner intima and media was dissected w/c lead to the pushing Saccular
of tunica adventitia to bulge
S/S: Pulsating Abdl Mass Low Back Pain Higher BP in Upper Extremities If RUPTURE occurs – could lead to SHOCK LAB DATA :
Altered Tissue Perfusion Risk for Injury
PRIORITY :
NO ABDOMINAL PALPATION bec it may lead to rupture – PLACE WARNING AT THE DOOR OF THE PT. Prepare pt for Surgery
CARDIO-PULMONARY RESUSCITATION (CPR) -
indicated for cardiac arrest when pt is BREATHLESS and PULSELESS;
shake the pt – are you ok? If breathless & pulseless then; ACTIVATE the EMS – Help! CPR (1 or 2 rescuer : 15 : 2) In 1 minute, there will be 80 compression and 15 – 20 rescue breaths Depth of Compression : 11/2” – 2” If too deep - it may fx the liver Effect of CPR : #1 (+) Pulse; #2 skin color
TIPS FOR CARDIOVASCULAR – ADULT
•
A nurse is assigned to a pt with arterial dses of lower extremities, w/c of the ff is expected – calf pain after short walking (intermittent claudication);
•
A pt was diagnosed w/ MI develop atrial fibrillation – this may possibly lead to – CEREBRAL EMBOLISM;
•
A pt w/ CHF was admitted exhibiting confusion, disorientation, visual disorders & hallucination – the nurse best action is to – CALL THE PHYSICIAN;
•
A nurse is assessing a pt w/ MI – w/c of the ff is the characteristic of PAIN – pain radiates to the jaw;
•
In utilizing mind over body principle for pt w/ HPN – w/c intervention is appropriate - relaxation and stress mgt;
•
Pt exhibits intermittent claudication – another sign of peripheral dses is w/c of the ff – tropic skin changes;
•
Ff MI, when shall I resume sexual activity? – when you can climb 2 plights of stairs w/o shortness of breath then sexual activity is safe;
•
A pt has R sided CHF, w/c of the ff is expected – hepatomegally;
•
Apt w/ CHF who is taking diuretics exhibits the ff, w/c requires further investigation (not expected to pt) – wt gain of 3 lbs in 2 days;
•
In addition to assessing a pt w/ Burger’s Dses, w/c of the ff data supports the Dx. – smoking;
•
A pt with R sided HF will manifest – distended jugular vein
RESPIRATORY General Consideration:
use the DIAPHRAGM of the steth when assessing breath sounds; use steth directly on pt. skin – because clothing my interfere w/ auscultation; when the pt chest is hairy, wet the hair w/ dump cloth – because dry hair interfere w/ auscultation
Consideration w/ Pediatric Patient:
when assessing pediatric pt, RR is affected when – therefore check RR FIRST;
Note for chest indrawing (if +, may indicate Pneumonia) and rapid breathing
Reportable Signs and Symptoms : common TO ALL RESPIRATORY DISORDERS “RE TACHY TACHY D C”
RETRACTIONS - #1 or Early sign for respiratory distress; Tachycardia
Tachypnea Dyspnea Cyanosis – late sign of respiratory Distress
Key Points for Assessment - note for abnormalities in RATE, RHYTHM & DEPTH Common CHARACTERISTIC in Breathing
BIOTS – increase in depth followed by apnea; - pt w/ neuro impairement Cheyne-Stroke – increase in rate and depth of breathing followed by apnea; - nero case Kussmauls – deep rapid breathing; Apneustic – forceful inspiration followed by slow expiration – dying patient
At birth, the child can maintain temperature by burning brown fat – and increase burning – bi products is Increase fatty acids that will cause acidosis – that can worsen the Resp. Distress Syndrome – a group of symptoms (mgt: maintain temperature). HYPOVENTILATION
Cause: Lack of O2
Effect: ACIDOSIS
HYPERVENTILATION ALKALOSIS Cause
: lack of CO2 – the pt will decrease rate of breathing to save CO2. co2 then combine with H2O to form carbonic acid – if inc, can lead to acidosis – and the brain will compensate by hyperventilating – and increase elimination of CO2 will cause ALKALOSIS.
APNEA OF INFANCY Occurs in Full Term Baby
SIDS/ CRIB DEATH Usually occurs in Pre-term
(37wks onwards)
s/s : episodes of APNEA, TACHYCARDIA and Cyanosis
Risk Factors:
a. b. c. d.
Pre-Term; Those w/ episodes of Apparent Life Threatening Events Siblings of those who died w/ SIDS (usually 2-3 sis/ bro – died) Hypoventilation
Dx Procedures: Cardioneumogram – measures O2 Polysonography ABG Analysis Tx :
• • •
Administer Theophylline (N 10-20 mg/ml) S/Effects: NAV and Insomia Caffeine Assist mother threu grieving process
Hx Teaching : Teach parents CPR
(esp to Apnea of Infancy)
ASTHMA MP : Inflammation of bronchioles that leads to excessive mucus production that resulted to narrowing and obstruction. Risk Factors : Environmental factors Emotion Effort/ Exercise S/S :
WHEEZING sound – due to obstruction Orthopnea Whitish Sputum
Lab Data :
Pulmonary Funx test Incentive Spirometer
Nsg Dx :
Ineffective airway Clearance
PI :
AIRWAY
Intervention : Bronchodilators – theophylline Rest Oxygen – low flow (1-2 l/min) –
higher than this will result to decrease in the stimulus for breathing – w/c is CO2
Nebulization Chest Physiotherapy – b4 meals or at bed time High Fowlers Intermittent Positive Pressure Breathing Aerosol Liberal Fluid Intake Meds :
Aminophylline Steroids Theophylline Histamine Antagonist Mucolytic Antibiotics
Hx Teachings :
Appropriate rest; Activity – avoid those that will expose pt to allergens; AVOID PROPANOLOL and ASPIRIN – causes BRONCHOSPASM; Exercise – “blowing exercises” – bubbles, trumpet
CYSTIC FIBROSIS -
multi system dses (GI and Respiratory System) characterized by excessive mucus production by exocrine glands.
Respiratory Hereditary For each pregnancy S/S :
GI Autosomal Recessive TRAIT TRANSMISSION – 50% Chance for DISEASE TRANSMISSION – 25%
MECONIUM ILEUS – within the 1st 24-36 hrs – if baby fail to defecate – suspect for CF; ABDL DISTENTION Malabsorption Syndrome – STEATORRHEA – foul-smelling stool w/ Inc Fats & Bulky Salty to Kiss – bec skin becomes impermeable to Na
Common Complications: MALE –
because of thick mucus plug
Aspermia – low sperm count Sterility
FEMALE – Difficulty in conceiving Nsg Dx :
Knowledge Deficit Altered Elimination Altered Sexual Functioning
Lab Data :
Sweat Chloride Test – N (if sweat) 10 – 35 mg/dl – INCREASE IF (+) CF (if serum) 90 – 110 mg/dl -do-
PI : since two system are affected: Respiratory Therapy – blowing of trumpet, Increase Fluid Intake; GI Therapy – Administer Pancreatic Enzyme (pancreatin, pancrease, viocase) GIVEN WITH EACH MEALS
Effective : if (-) fat at stool Hx Teaching : Refer parents to GENETICIST
CROUP DISORDER ACUTE LARYNGITIS
LTB
RSV/ BRONCHIOLITIS
(Laryngotracheal Bronchitis)
(Respiratory Synctial Virus)
common in TODDLER
INFANTS & TODDLER
INFANTS usually (less than 6 mos)
VIRAL
VIRAL or BACTERIAL
VIRAL
Inflammation of LARYNX
Inflam. of LARYNX & TRACHEA Inflam. Of BRONCHIOLES
“barking-metallic cough”
“harsh-brassy cough”
“paroxysmal-hacking cough”
(-) FEVER
(+) FEVER-low grade
(+) FEVER-moderate
(+) STRIDOR
(+) STRIDOR
(+) WHEEZING
STRIDOR – is present when the affected part is LARYNX.
Lab data: Nsg Dx : PI :
P Exam ABG’s
-do-
ELIZA -do-
INEFFECTIVE AIRWAY CLEARANCE
Airway – Endotracheal Tube (Tracheostomy Set - #1) – to facilitate airway; Humidity – place infant in MIST TENT or CROUPETTE Nsg care:
change clothing frequently coz mist will dampen child clothings;
TOYS while inside the tent: PLASTIC TOYS “no battery operated & no friction wheel toys” at HOME: we can use NIGHT or MOIST air outside and hot shower mist at the comfort room – for child to inhale
Antibiotics – Antiviral – Ribavirin Hx Teachings : SYRUP OF IPECAC – for Croup – it induces vomiting- bec it will stop the spam thereby preventing further coughing.
Chronic Obstructive Pulmonary Disease (COPD) MP :
group of disorders of respiratory system that lead to obstruction or narrowing of airways.
EMPHYSEMA
BRONCHITIS
ASTHMA
Over distention of Alveoli
Inflammation of Bronchus Gelatinous sputum + “RE TACHY TACHY D C”
Risk Factors: (+) (+) (+) (+) (+) S/S:
Allergy Environmental factors Pollen Elevated Immunoglobulin E (IgE) Smoking (esp to passive smokers)
RE TACHY TACHY D C + “barrel-shape test” – there is an INCREASE in ANTERIOR and POSTERIOR DIAMETER of the chest
Lab Data : ABG’s – to check for respiratory acidosis CXrays Nsg Dx : #1 Ineffective Airway Clearance – due to narrowing & obstruction
#2 Ineffective Breathing Pattern PI :
AIRWAY 1-2 L/min; Meds: Bronchodilator – Atrovent
Exercise: Blowing; Rest periods in between activities
During ACUTE attack, the POSITION OF CHOICE : ORTHOPNEIC
PNEUMOTHORAX MP : partial or total collapse of lungs due to: Types :
• • • S/S :
over distention of alveoli
Diminished Breath Sounds – (-) b. sounds to area auscultated; (+) Dyspnea; (+) Restlessness
Nsg Dx :
PI :
Open Pneumothorax – TRAUMA Spontaneous Pneumothorax - due to rupture of BLEB – Tension Pneumothorax – due to INCREASE IN TENSION
Impaired Gas Exchange Ineffective Breathing Pattern
Chest Tube Drainage System – restores the (-) pressure within the thoracic cavity Anterior chest tube – drains the AIR Posterior chest tube – drains FLUIDS
PNEUMONIA (PNA) MP :
there is INFLAMMATION of ALVEOLAR SPACES that leads to exudation and consolidation of the lungs.
LEGIONARES DSES – acute bronchopneumonia in elderly, alcoholic & Immunosuppressed pt - management same w/ pna
VIRAL PNA
BACTERIAL PNA
Fever :
(+) low-moderate
(+) fever moderate-high
Cough :
(+) Non productive – “thin-watery” (+) Productive – “rusty”
WBC :
No change or slight
Lab Data :
Xray and ABG’s
Nsg Dx :
Impaired Gas Exchange – due to exudation and consolidation of Alveoli
Elevated
PI : • • • • • •
Airway – O2 Position : Semi-fowler’s or Orthopneic Bed Rest Inc Oral fluid intake Antibiotics TCDB (turning, coughing, & deep breathing)
TB
HISTOPLASMOSIS
Bacterial
Fungal (from HISTOPLASMA CAPSULATUM)
MYCOBACTERIUM AVIUM COMPLEX Bacterial
from BIRD MANURE – soil & transmitted thru inhalation
Droplets & Airborne Droplets & Airborne
Droplets & Airborne
Risk Factors: ASIAN IMMIGRANT IMMUNOSUPPRESSION MALNUTRITION
S/S :
same: a to e + FOREST RELATED ACTIVITY
same with TB
Ask client if came from AVIARY
a. initially asymptomatic; b. low grade fever that occurs in the afternoon; c. body malaise or weakness; d. coughing w/ bld streaked sputum; e. weight loss Lab Data :
Histoplasmine Skin Test – for Histoplasmosis
Mantoux Test Xray – confirmatory test Sputum - @ least 2 (-) to be effective
Nsg Dx : Infection; Ineffective Breathing Pattern
•
PROPHYLACTIVE TREATMENT OF TB –
MEDS :
Antiviral Meds
INH for TWO WKS (take Vit B6 to avoid NEUROPATHY) Antibiotics
Rifampicin INH Streptomycin Ethambutol
-
take above meds for 6-12 moths to avoid resistance
TIPS FOR RESPIRATORY
you observed a nurse caring for a child in a CROUPETTE, if you are the nurse incharge, what would be your #1 PRIORITY? – changing the linens & clothings to keep child always dry;
which data in the past medical history of the pt. supports a dx of cystic fibrosis – MECOMIUM ILEUS in the neonate;
the primary goal of care for pt w/ bronchiolitis is to – minimize oxygen expenditure;
w/c of the ff intervention being carried out by LPN would require immediate intervention – suctioning the pt for 20 seconds;
a client w/ TB will experience - low grade fever;
a pt is diagnosed w/ emphysema – w/ of the ff s/s would the nurse expect to have – barrel shape chest;
a nurse caring for a pt w R Lower Lobe PNA shld put the pt in w/c of the ff position to enhance postural drainage – L Lateral w/ the Head Lower than the Trunk
DAY 7 (Feb 10, 2005)
ENDOCRINE General Consideration Explain to the pt the MOST COMMON METHOD of assessment: a. Direct methods – specimen : blood and urine b. Explain the methods of gathering the specimen Consideration for PEDIATRIC PATIENT a. Involve the parents of the child; b. Incorporate food preferences 2 servings of popcorn – HOW MANY RICE TO GIVE UP = 1 if sandwich = 1 rice
c. self insulin administration – allowed to child 9 yo and above Reportable S/S :
skin changes – “have you noticed any change in your skin color”
Inc. temperature S/S of Shock
(“bronze skin pigmentation – addison’s dses)
Keypoints :
Specimen characteristic is usually affected by STREE, DIET and
Normal Body Rhythm
PKU -
AUTOSOMAL RECESSIVE PATTERN of transmission (inherited)
MP : There is Absence of Phenylalamine Hydroxylase (the one that converts Phenylalamine to Thyroxine ( a precursor to Melanin). Therefore (-) PH leads to accumulation of phenylalanine at the brain that leads to Mental Retardation. S/S :
Initially – asymptomatic For OLDER CHILDREN :
Since (-) melanine: Lab Data :
Diarrhea Anorexis Lethargy Anemia Skin Rashes and seizure Musty odor of urine (due to phenyl pyruvic acid) hair : blonde Eyes: blue Fair Skin
GUTHRIE CAPILLARY BLD TEST – initial screening – done after the infant has ingested CHON for a minimum of of 24 hrs.
Secondary screening : done when the infant is about 6wks old – test fresh urine w/ PHENISTIX – WHICH CHANGE COLOR
Phenylalanine level greater than 8mg/dl – diagnostic of PKU
(4mg/dl – indicative)
Nsg Dx :
Knowledge Deficit Altered Thought Process Risk For Injury PI :
Dietary Modification : LOW CHON and Low Phenylalanine Diet until adolescent or til 10 yo – bec b4 this time the brain mature
MEDS :
Lofenalac – 20-30mg/kg/day
Hx Teachings :
Inform parents of the foods to be avoided; - prepare special education to parents Provide list of foods allowed;- prepare special education to parents Refer to geneticist
Untreated PKU can result in failure to thrive, vomiting and eczema – and by about 6 mos, signs of brain involvement appear.
LYMPHOCYTIC THYROIDITIS or JUVENILE HYPOTHYROIDISM Cause :
Autoimmune or genetics
MP :
Decrease in T3 and T4
S/S :
Dysphagia Enlarge thyroid All s/s of hypothyroidism (decrease metabolism)
Nsg Dx :
Knowledge Deficit Activity Intolerance
PI :
no tx because it regresses (only temporary) spontaneously
CRETENISM or CONGENITAL HYPOTHYROIDISM -
disorders related to absent or non-functioning thyroid; newborns are supplied with maternal thyroid hormones that last up to 3 mos; initially asymptomatic s/s begins 2 – 3 months
behavioral s/s
physical s/s –
- apathy – “well behave”
-
large tongue & protrudes from mouth retarded growth intolerance to cold
mental retardation
Prevention: neonatal screening blood test; Without treatment, mental retardation and developmental delay will occur after age 3 mos;
Lab Data :
Decrease T3 and T4
Nsg Dx :
Knowledge Deficit Risk for Injury
Meds :
Single morning dose of Synthroid for “LIFE” – oral thyroxine and Vit D as ordered to prevent M. retardation (adverse effect of meds : insomnia, tachycardia, and nervousness – REPORT ASAP)
PI :
correct the deficiency
Hx Teachings :
Warm environment (bec there is Hypothermia w/ cool extremities); Low calorie diet : since there is decrease metabolism; Special education
ENDOCRINE GLANDS 1. 2. 3. 4. 5. 6. 7. 8.
8 glands (ductless)- they secrete the hormone directly to bld stream
Pineal Gland Pituitary Gland Thyroid Gland Parathyroid Gland Thymus Gland Pancreas Adrenals Gonads (testes & ovaries)
Glands
UNDER
OVER
PITUITARY
Diabetes Insipidus
SIADH
THYROID
Hypothroidism (Myxedema)
Hyperthyroidism (Graves, Basedows, Parrys)
PARATHYROID
Hypo
Hyper
Pancreas
DM
ADRENALS
Addison’s Dses
Cushings Conns
PANCREAS Alpha Cells
BETA CELLS
Islets of Langerhans Glucagon
Insulin
(responsible for Decrease in blood sugar)
Responsible in the increase Blood Sugar
Absence (DM Type I) IDDM
Juvenile Onset – B4 age of 30 Adolescence to Early Adult Stage Pt is THIN Pt is KETOSIS PRONE
Deficiency (DM Type II) NIDDM Maturity Onset – After age of 30; Pt is Obese NON-KETOSIS PRONE
MODY – DM III -
combines features of DM Type I & 2; Maturity Onset that occurs in young adult; OBESE, b4 age of 30 Non-Ketosis Prone
GESTATIONAL DIABETES
- occurs during pregnancy
Types According to WHITE’S Classification TYPE
ONSET
DURATION
A
CHEMICAL DIABETES
(+) Increase Bld Sugar
B
After the age of 20
10 years
C
Bet 10 – 19 yrs old
10-19 years
D
Before 10 yrs old D1
More than 20 yrs
Before 10 yrs old
D2
>20 yrs
D3
Beginning Retinopathy
D4
w/ calcification of arteries
D5
DM w/ HPN
E
w/ calcification of Pelvic Arteries
F
w/ nephropathy (Diabetes Nephropathy)
H
Diabetes Cardiopathy
R
Diabetes Retinopathy
T
w/ Transplant of the Kidney
DIABETES MELLITUS MP : Deficiency in INSULIN – either absence or deficiency of insulin that leads to alteration in the metabolism of CHO, CHON and FATS. Cause:
unknown
R. factors :
Autoimmune Genetic Stress
S/S :
Polydipsia Polyuria Polyphagia Wt loss
Nsg Dx : PI :
– the stave cells send message to the brain to eat more
Knowledge Deficit Altered Nutrition
Correct the deficiency- HOW?
Diet : well balance diet – CHO – 50-70% (main source of energy and sugar for DM pt.) Insulin – for Type 1 Hypoglycemia Most Approximately to Occur
RAPID
Regular Insulin - BEFORE LUNCH
INTERMEDIATE SLOW INSULIN:
NPH
- LATE IN THE AFTERNOON/ AFTERNOON
Protamine Zinc - DURING NIGHT Ultralente
Best Site is ABDOMEN bec it is a NEUTRAL AREA
SUBQ – 90 degree angle for insulin syringe 40 degree angle if non-insulin syringe Complication of INSULIN ADMINISTRATION:
Lipodystropy Dawn’s Phenomenon – hyperglycemia that occurs at dawn –
SOMOGYI Phenomenon – rebound hyperglycemia
Early AM - due to over secretion growth hormone treatment: GIVE INSULIN – NPH at 10 PM to prevent hyperglycemia at early AM
Antidiabetic Agent;
Blood Sugar Monitoring – in AM and supper time (2x a day);
Ensure adequate food intake;
Transplant of Pancreatic Cells;
Exercise – it will decrease insulin requirement
Scrupulous foot care
(tx: administer insulin)
(in pregnancy/stress – Increase insulin req)
– check up w/ podiatrist - foot powder, snugly fitting shoes, cut toe nail straight across - cut toe nail across - avoid going barefoot - always dry in between toes
Modification for Pregnant Pt with DM •
•
+300Kcal; Insulin Requirement (dose will be adjusted on 2nd & 3rd Trimester); AM Dose: PM Dose:
2:1 for Regular to NPH 1:1 for R:NPH
EFFECTS
MOTHER Macrosomia Hyperglycemia Therefore pre-term birth Complication: Uterine Atony
BABY Hypoglycemia RDS Congenital Defects
COMPLICATION
1. Hypoglycemia (Insulin Reaction) - BLD SUGAR BELOW 50
Hyperglycemia (bld sugar level above 120) (Diabetic Coma)
DKA
HHNK
Risk Factors :
Missed meals; Increase or Overdose of Insulin;
Overeating Decrease Insulin
Too much Activity
Inactivity Stress Infection
S/S : Dizziness Drowsiness Difficulty Problem Solving Decrease Level of Consciousness + Cold Clammy Skin, Diaphoresis Lab Data : Below 50 Blood Sugar Level PI :
Administer Simple Sugar (fructose-fruit juice) Hard Candy (not chocolate – it is complex sugar) If unconscious – D50
DKA (Type 1)
HHNK (Type 2) (Hyperglycemic Hyperosmolar Nonketotic Coma)
S/S : 3 P’s + Signs of Dehydration – thirst & warm skin
Hyperglycemia “Kussmaul Breathing + 3P’s Thirst and warm skin Lab Data :
Increase Bld Sugar
PI :
#1 AIRWAY #2 Fluid Regular Insulin
Nsg Dx :
Risk for Injury
More pronounced GI Disturbances
2.
MICROANGIOPATHY
3.
ATHEROSCLEROSIS –
4.
NEPHROPATHY
- destruction of small blood vessels; hardening of arteries;
– kidney damage;
5.
OPTHALMOPATHY
6.
Peripheral Neuropathy or Autonomic Neuropathy -
- w/c leads to cataract
(eye exam annually);
there is poor nerve impulse transmission common manifestation : impotence
DIABETES INSIPIDUS
(Pituitary Glands – 3 lobes)
ANTERIOR
POSTERIOR
MIDDLE
Secrete Tropic Hormones
Store Only (does not excrete)
MSH (skin color)
FSH OXYTOCIN (follicle stimulating Hormone) ADH
ACTH (adrenocorticotropic hormone)
LH (luteinizing hormone);
GH (growth hormone);
Prolactin
PITUITARY GLAND ADH (anti Diuretic Hormone)
Deficiency: lead to D. INSIPIDUS
– retain h20 or flds
Excess : SIADH
(Syndrome of Inappropriate Anti Diuretic Hormone Secretion)
Due to or related to: Pituitary Tumor Head Trauma Injuries
MP : Deficiency in ADH leads to fld excretion, therefore s/s same with DM EXCEPT : POLYPHAGIA
Polyuria – 21 L/day Polydypsia
LAB DATA : a. urine - decrease in specific gravity (N 1.010 – 1.025) – in DI its <1.005; b. FLUID DEPRIVATION Test - pt on NPO 24hrs B4; Nsg Dx :
FLUID VOLUME DEFICIT
PI :
Administer IV Fluids Meds - Synthetic ADH - Vasopressin – IM Desmopressin – INTRANASALLYLypressin -doHow :
Given as pt exhale to the mouth then inhale thru the nose then EXHALE to the mouth then give meds.
Evaluate the effect of meds :
one hole of nose only
Check Specific Gravity of Urine; Monitor I & O; Monitor V/S : assess for hypovolemic shock
SIADH -
excess ADH;
MP : Fluid Retention – result to DILUTIONAL HYPONATREMIA or H2O INTOXICATION S/S :
due to DECREASE NA – this could lead to the ff:
convulsion; seizure; HPN
Above s/s could lead to decrease LOC LAB DATA : Decrease Na Level (<120 mEq/L) – hyponatremia Nsg Dx :
FLUID VOLUME EXCESS
PI :
FLUID RESTRICTION Drugs – DIURETICS + ANTIHPN –
if cause by TUMOR – PREPARE PT FOR SURGERY IF after surgery – POLYURIA – report ASAP – sign of DI
PITUITARY GROWTH HORMONE DEFICIENCY DWARFISM - “congenital” ex. MAHAL
NANU’S SYNDROME (hereditary)
Lab Data :
EXCESS B4 Closure of Growth Plate - “gigantism” - long, slender extremities and Inc. in Height ex. Marlo Aquino
After the Closer of Growth Plate - “acromegally” - there is coarsening of facial features + enlargement of the digits (inc. shoe size) ex. Balingit
INCREASE HUMAN GROWTH HORMONE
Increase Blood Sugar Nsg Dx :
Risk for Injury
PI :
Safety Meds - Parlodel – decrease secretion of growth hormone If related to tumor : surgery
GIGANTISM (long slender extremity)
MARFAN SYNDROME (hereditary) MP : Cardio & Eye disorder Scoliosis
KLINEFELTERS (chromosomal aberrations) MP : XXY Pattern (an extra X chromosome)
(complication)
X chromosome – FEMALE COMPONENT of HUMAN BODY Problem is NON-DEVELOPMENT of SEX ORGAN
ADRENAL/SUPRARENAL
CORTEX (OUTER) RESPONSIBLE FOR SECRETION OF:
GLUCOCORTICOIDS
MINERALOCORTICOIDS
MEDULLA
(INNER) SECRETES THE FF:
EPINEPHRINE
NOREPINEPHRINE
(ALDOSTERONE) GLUCONEOGENESIS STRESS RESPONSE – “fight or flight” - formation of sugar from Responsible for Na Retention new sources and K Excretion
DEFICIENCY IN GLUCO & MINERALO :
ADDISON’S Dses
EXCESS of GLUCO & MINERALO :
CUSHING’S Dses/ syndrome
EXCESS of MINERALOCORTICOIDS ONLY : CONN’S SYNDROME
ADDISON’S
CUSHING
MP : Underactivity of the Adrenal Glands Overactivity of A. Glands (there is DEC G, M & SEX HORMONES) (there is INCREASE G & M) ADRENOCORTICAL INSUFFICIENCY
CONN’S INC. MINERALOCORTICOIDS - w/c cause K EXCRETION & Na RETENTION
Excessive SECRETION of - coticosteriods especially the GLUCOCORTICOID CORTISOL
Common: Male and Female
Excessive ALDOSTERONE Secretion from A. Cortex
Female (bet. Age 30-60)
Female (30-50)
RF : Could be related to Surgery – removal Related to Tumors
Related to Tumor
Of Adrenal Gland and or Auto Immune Reaction
S/S: Dec Bld Sugar (hypoglycemia)
INC BP, NA ALL S/S OF CUSHINGS DEC K + EXCEPT HYPERGLYCEMIA Moonface, Hirsutism, Buffalo Hump, Pendulous Abdomen Hypertension Lability of Mood (mood swings) Polyuria, Polydipsia Depression Cardiac Arrythmias – due COMPENSATORY of MSH – Inc w/c Trunkal Obesity / thin Extremities to dec K Leads to “Bronze-Like Skin Pigmentation” Hypertension Decrease Resistance to Infxn Hypotension, Weak Pulse Weight loss, Fatigue, Muscle weakness Nausea, Anorexia, Vomiting Hx of frequent Hypoglycemic Rxn Dec Na (hyponatremia) Dec BP INC K (hyperkalemia)
Lab Data : Decrease Cortisol Level
Increase Cortisol Level Hypernatremia Hyperglycemia Hypokalemia
Hyponatremia Hypoglycemia Hyperkalemia
Hypokalemia – due metabolic Alkalosis Inc Urinary Aldosterone Level Decrease K
Nsg Dx : Fluid Vol. Deficit Fld & E imbalance
Fld Vol. Excess Fld & E imbalance
ADDISON’S
Risk for Injury Fld & E Imbalance
CUSHINGS
CONN’S
PI :
Correct the imbalance – IV Diet: Inc Na Dec K Administer Steroids (Fludocortisone) Admin. Hormone Replacement Therapy Cortisone – give 2/3 of dose in AM 1/3 in afternoon
Meds are FOR LIFE
Correct the imbalance
DIET : Low in Calories & Na High in CHON, K, Ca & Vit D
Prevent accident & Falls
Prevent exposure to Infxn
Diet : Low Na, Inc K
Minimize stress in environment MIO & weigh Daily
Provide small, frequent feeding high in CHO, Na and CHON to prevent Hypoglycemia & Hyponatremia
Use of Table salt tablets (if Rx) or ingestion Surgery – prepare pt if cause Of salty foods (potato chips) by pituitary tumor or hyperplasia if experiencing Inc. sweating Post Surgery: poor wound healing; report s/s of Addisonian Crisis – severe HYPOTENSION
Avoidance of strenuous exercise esp in HOT WEATHER
Monitor V/S, observe for HPN & edema
Meds: FOR LIFE Glucocorticoids Synthesis Inhibitors - Lysodren and Cytodren - prevents formation of Gluco…
Administer SPIRONOLACTONE (aldactone) & K supplements
As Rx
ADDISONIAN CRISIS
Limit the flds
Protect client exposure to Infxn
Provide rest periods – prevent fatigue Monitor I & O, weigh Daily
Check BP – give antiHPN
- limit fld intake
-
severe exacerbation of Addison’s dses caused by acute adrenal insuffieciency
causes:
strenuous activity, infection, trauma, stress, failure to take RX Meds
s/s:
severe generalized muscle weakness severe hypotension hypovolemia, shock
PI :
administer flds to treat vascular collapse IV glucocorticoids - Solu-Cortef and Vasopressors Maintain strict bed rest and eliminate all forms of stressful stimuli MIO and weigh daily Protect client from Infxn Other Hx teachings: same with Addison’s
THYROID T3 & T4 - responsible for maintenance of
Calcitonin
METABOLISM
DEFICIENCY HYPOTHYROIDISM Adult: Myxedema Children: Cretenism
- deposit Ca @ bones
EXCESS HYPERTHYROIDISM Grave’s Disease, Basedow’s or Parry’s Dses
Main Problem: Slowing of metabolic process caused by hypofunction of the Secretion of excessive amount of Thyroid Thyroid Gland with decrease thyroid hormone secretion (T3 & T4) Hormone in the blood causes in the INC Of metabolic process DEFICIENCY in T3 and T4
Excess in T3 and T4
Causes:
congenital surgery autoimmune
genetic autoimmune tumor
S/S : FACIAL EDEMA INTOLERANCE to COLD DECREASE v/s DECREASE GI Motility – constipation HYPOactivity Increase Sleep – hypersomnia Wt Gain in the presence of Dec Appetite Dry scaly skin, dry sparse hair, brittle nails
EXOPTHALMUS (+) Goiter Hypermetabolic State INTOLERANCE to HEAT Inc V/S INC GI Motility - DIARRHEA Insomnia HYPERactivity WT LOSS even INC Appetite Warm smooth skin, fine soft hair Pliable nails Irritability, restlessness, agitation
LAB DATA : Check TSH (increase) DECREASE T3 & T4 DECREASE RAIU (131) INCREASE Serum Cholesterol Level
DECREASE TSH INCREASE T3 & T4 INCREASE RAIU
RADIOACTIVE IODINE UPTAKE (RAIU) – administration of 123I or 131I orally; - performed to determine thyroid function (increase uptake – indicated hyperthyroidism, minimal uptake may indicate – hypothyroidism); nsg consideration : take a thorough history – thyroid meds must be D/C 7-10 days b4 the test – meds containing iodine cough preparations, and intake of iodine rich foods and test using iodine – eg IVP can invalidate the test
NSG DX : Activity Intolerance – due to Fatigue (fatigue – due to hypometabolism) PI :
Risk for Injury (bec of hyper)
Promote a EUTHYROID STATE
HOW :
same
a. THYROID SUPPLEMENT Synthroid, Cytomel – lifetime s/e: insomnia, palpitation nervousness b. DIET: low calorie
Admin AntiThyroid Meds – for LIFE ex. PTU & Lugols Assign to private room away from excessive activity
c. Maintain vital funx: correct hypothermia – maintain adequate ventilation d. Provide comfortable, warm environment e. Increase flds and high fiber foods to prevent constipation,. Admin stool softener as Rx f. Meds: thyroid hormone replacement – take daily dose in AM to avoid insomnia Monitor THYROTOXICOSIS – tachycardia Palpitations, nausea, vomiting, diarrhea, Sweating, tremors, dyspnea
Quite & relaxing Activity Provide a COOL ENVIRONMENT DIET : High in CHO, CHON, CALORIES Vit & Minerals w/ supplemental feedings bet meals & at HS NO STIMULANTS tears
Protect eyes w/ dark glasses & artificial
Monitor for AGRANULOCYTOSIS (fever, Sore throat & skin rashes) – if taking antithyroid meds. Prepare pt for surgery – 2wks before SURGERY give LUGOL’S SOLUTION - it decrease size and vascularity of thyroid gland; - give w/ straw to avoid staining teeth; - can be diluted w/ H2O or orange/ apple juice; - report diarrhea & metallic state
Meds:
a.
Antithyroid Drugs – Prophythiouracil and Tapazole - block synthesis of thyroid hormone; - toxic effect include AGRANULOCYTOSIS
b. Radioactive Isotope of Iodine (131) – Radioactive Iodine Thrapy - given to destroy the thyroid gland thereby decreasing Thyroid hormone production
COMPLICATIONS OF THYROID SURGERY:
MEMORRHAGE – whether the dressing is dry or intact – its not a confirmatory that there is no bleeding. To check, slip your hands at the back of the neck (bec of principle of gravity)
Damage Laryngeal Nerve – to assess, ask pt to talk past surgery and if pt has APHONIA – provide communication aids – paper and pencil
LARYNGOSPASM – accidental removal of parathyroid gland – therefore will lead to dec parathormones – w/c lead to dec Calcium and laryngospasm – KEEP TRACHEO SET at bedside.
TETANY – due to decrease in CA – characterized by: a. tingling sensation – fingers & lips b. Chvostek’s Sign – facial muscle twitching on percussion of facial nerve c. Trousseau Sign – carpopedal spasm
THYROID CRISIS – due to rebound hyperthyroidism Increase thyroid hormone Increase HRate/palpitation Inc Temp - hyperthermia
PARATHYROID Parathormone
Deficiency
HYPOPARATHYROIDISM
Inc CA in the Blood
EXCESS
withdraws Ca @ bone to the bld
MP : Dec Ca (hypocalcemia) maybe hereditary, Or caused by accidental damage to or removal Of parathyroid glands during surgery eg thyroidectomy
HYPERPARATHYROIDISM
Increased secretion of PTH that result in altered state of Ca, Phospate & bone metabolism
S/S : Initial S/S: -
-
Tingling lips & Fingers Chvostek’s
Bone Pain (esp Back Bone) Kidney Disorder – kidney stones renal colic
Trousseau
NAV, Constipation
Late S/S -
personality changes cardiac arrythmias muscle pains
Lab Data : Decrease Ca Serum Phospate Inc Skeletal Xray – reveal Inc Bone density Nsg Dx : PI :
RISK FOR INJURY
Inc Ca (N 4.5-5.5 mg/dl) Dec Serum Phospate Level xray –reveal Bone Demineralization same
a. Safety
same
b. Keep Ca supplement at Bedside c. Diet: Inc Ca – spinach, sardines, seafoods d. Tracheo set – deu to dec Ca – Laryngospasm
Inc Oral Fld intake – due to renal calculi of having INC Ca Diet; Low Ca Surgery – if due to tumor
TIPS FOR ENDOCRINE
a child w/ PKU was admitted, w/c of the ff statements made by the mother indicates a need for further instruction – “my child loves to drink milkshakes” – chon- w/c has INCREASE Phenylalanine;
w/c of the ff if manifested by a child could be indicative of diabetes – bed wetting;
a common manifestation of HYPOGLYCEMIA – shaky tremors;
a pt post thyroidectomy develops tetany, the nurse anticipates that the doctor will most likely order – Ca Gluconate;
rapid & deep breathing that occurs in diabetic pt is indicative of – KETOACIDOSIS
a pt is to receive NPH Insulin at 8AM, when shld the nurse expect to have hypoglycemia – in the late afternoon;
to determine the effect of PTU, the expected outcome is – Dec HR;
what would be the question to support the Dx of Hypothyroidism – do you tire easily?;
w/c of the ff statements made by the diabetic pt would indicate the need for further teaching – “I will be hypoglycemic if I experience emotional stress”.
GENITO-URINARY General Consideration
when performing assessment of Genito-urinary system, use open-ended question- bec some pt are not comfortable talking genitals; explain the meaning of terminologies; ask the patient what symptoms bother him/her the most;
Consideration for Pediatric Patient
assess for history of sorethroat; bladder capacity increase with age infants – about 65ml toddler – 300-400 ml school age – 800 – 1000 ml
infants are unable to concentrate urine until the age of 1 – therefore – adequate milk intake if baby has 6-8 diapers /day;
bladder sphincter control develop at around 2 yo (therefore, bladder trng comes after bowel trng – 15-18 mos of age)
S/S common to all Disorders of GU: a. frequency b. urgency c. hesitancy Reportable s/s :
peri orbital edema BP Oliguria Hematuria – Early Stream Hematuria – indicate lesion at Urethra Late Stream – indicate lesion at bladder
Key points : a. check for wt gain if >1lb/day – indicative of fld retention b. characteristic of urine: color N - amber if pinkish – bldg brownish – flagyl orange – rifampicin c. s. gravity (N 1.010 – 1.025) - if INCREASE - D. Insipidus DECREASE – D. Mellitus
d. Increase glucose – UTI e. Elevated CHON – Nephrotic Syndrome or PIH Epispadias – opening at DORSAL portion Hypospadias – opening at VENTRAL portion
WILM’S TUMOR S/S :
congenital tumor at the kidney common in L Kidney and children below 5 yo
Unilateral Abdml Mass Hematuria HPN
Lab Data : CT Scan IVP NO INAVSIVE LAB/ Procedure NO BIOPSY Nsg Dx : PI :
Knowledge Deficit Risk for Injury
AVOID/ NO ABDOMINAL PALPATION Prepare pt for Surgery and Chemotherapy
NEPHROTIC SYNDROME
AGN
MP : Altered Kidney Funx related to inability to retain CHON Destruction of Kidney Tissues related (therefore there is PROTEINURAI) causes: Autoimmune congenital
to Group A Beta Hemolytic Streptococus sorethroat
S/S EDEMA: Peri-orbital Edema but subside at the end of the day
Periorbital but progresses to generalized at the end of the day
BP :
Decrease or N
INCREASE BP
URINE :
Frothy
Tea colored or Cola colored or Smoky
LAB DATA (+) Proteinuria, severe - >10mg in 24 hrs
Nsg Dx :
(+) Proteinuria - <10 mg/ 24hrs urine
Fld Volume Excess Impaired Skin Integrity
PI : Check BP Maintain Fld Balance Meds : NO Antihypertensive (+) Steroids (+) Antibiotics
Antihypertensive Diuretics
DIET : INCREASE CHON, Low Na
LOW CHON and Na
POSITIONING : Turn Patient frequently – because pt w/ edema are prone to skin integrity like pressure sore formation
CYSTITIS -
Infection of the bladder Ascending infection caused by E. Coli (from feces) or Pseudomonas
RF : Wearing silk underwear (does not absorb moist); - use COTTON Bubble bath Prolong driving Common in FEMALE – due to size (short) urethra S/S: FREQUENCY, URGENCY & HESISTANCY + Burning sensation on urination (dysuria) LAB DATA :
Urinalysis – to check for microorganism
Nsg Dx :
Altered Elimination Pattern Infection
PI :
Treat for Infection – antibiotics for 10-15 days
Diet :
ACID-ASH DIET – give lemon juice or VIT C
Bladder Analgesic (ex. PYRIDIUM – ch can cause ORANGE COLORED URINE, effective : (-) pain)
Hx Teachings: Avoid bubble Bath No Silk underwear Inc. Fld Intake
RENAL FAILURE ACUTE MP
CHRONIC
Sudden or Acute, Usually Reversible loss of Kidney Funx
IRREVERSIBLE kidney damage that leads to scar formation
There is inability of kidney to maintain fld & E balance
PHASES
Causes
:
Pre-renal Factors – those that dec bld circulating vol. – SHOCK;Phase I: RENAL INSUFFICIENCY Intra-Renal – dses condition of the kidney eg. AGN Post-Renal – those that causes obstruction eg. Kidney stones Polyuria Nocturia Polydipsia
Phases of ARF
OLIGURIC PHASE - decrease urine output that is less than 400 ml/24hr - Dec NA & Inc K DIURETIC PHASE - Inc urine output (4-5L/day) - Dec Na & K RECOVERY PHASE - renal funx normalizes
PHASE II : MILD RENAL DAMAGE (OLIGURIA)
There will be INC BUN & Crea
RENAL FAILURE All s/s + Anemia & HPN ESRD
(1-2 yrs)
LAB DATA Increase BUN and Crea – most sensitive Index
Azotemia & Uremia – accumulation of waste products “uremic frost” – skin pruritus same
Nsg Dx Fld and E Imbalance
PI :
Fld & E Imbalance Activity Intolerance
TO CORRECT THE IMBALANCE A. B.
Fluid restriction; Meds : Diuretics Cardiac Glycosides – Digitalis Antihypertensive
Fld restriction Amphogel – to promote excretion of Phospate Epogen – Inc RBC synthesis Diuretics AntiHPN Diet: same
C. DIET : Low CHON – NO PMS
DIALYSIS PERITONEAL
HEMODIALYSIS
Semi-permeable membrane: Abdomen (peritoneum) Use of Tenchkoff Catheter Teachings:
Dialyzing machine Use of fistula or shunt
anastomosis of artery & vein (internal access) – less prone to infxn
Report Infxn (abdomen: rigid, Solution : cloudy)
Check BT and CT
external access
Check Temp of dialyzing solution
(more prone to infxn)
Complications of dialysis (report ASAP): 1.
DISEQUILIBRIUM SYNDROME – due to rapid removal of solutes (electrolytes and CHON) s/s: GI – nausea, vomiting, headache CNS - convulsion, seizures
2. DIALYSIS ENCEPHALOPATHY – due to aluminum toxicity s/s: (+) dementia muscle abnormalities – twitching seizures RENAL TRANSPLANT – s/s of complication : FLANK PAIN, FEVER, TENDERNESS, HPN - REPORT
BPH -
glandular enlargement of the prostrate common in males above 40 yrs old
S/S : Decrease size and force of urinary stream Nocturia Frequency, hesitancy and urgency LAB DATA:
Digital rectal exam – once a yr for pt 40yo and above gloves, ky jelly position: Sim’s
Nsg Dx :
Altered Elimination Pattern
PI :
Prepare pt for surgery TURP – no incision Suprapubic Prostatectomy Retropubic -do Perineal -do- - common complication: IMPOTENCE due to nerve damage “I am eager to have sex again” – cannot be bec pt is impotence
nsgcare :
CBR for 2-3 days post surgery; NO LONG DRIVE/ SITTING; Ff up check up (if INC ACID PHOSPATASE: Prostate CA)
TIPS FOR GENITOR-URINARY
A common sign of ARF – OLIGURIA;
After peritoneal dialysis, w/c of the ff is appropriate action – turn pt to side;
To prevent cystitis, w/c of the ff the nurse must instruct to the pt to do – take a bath using the shower rather than bubble bath;
For early detection of prostrate CA the nurse shld emphasized – digital rectal exam annually to screen for prostrate CA in men 40 yo and above;
In a pt with BPH, the nurse shld expect that the pt will probably have the symptoms – residual urine of more than 50 ml;
A male pt has an arteriovenous fistula in his L forearm, w/c behavior would indicate that the pt needs further instruction in self care – he wears a watch on his L wrist;
w/c of the ff indicates complication of peritoneal dialysis – cloudy dialysate
DAY 8 (Feb 11, 2005)
EENT General Consideration
Explain to the patient there there will be no or little discomfort when performing EENT exam; Explain the methods of assessment to the patient;
Consideration to Pediatric Patients
Obtain feeding history (bec the type & techniques differs) Obtain the diet hx of the pt and hx to URTI Involve the parents in the assessment of the baby
Reportable Signs and Symptoms
TINNITUS - ringing, buzzing or sea shell sound in the ear VERTIGO - Objective – “the room is spinning” Subjective – “I feel that I am revolving/rotating”
Hearing Loss Pain – if pain subside or (-) – rupture of ear drum
Keypoints for Assessment
Note for abnormal findings Document the subjective and objective complaints
OTITIS MEDIA -
infection of the middle ear
RF : Faulty feeding practices Swimming in dirty waters Upper Resp. Tract Infection S/S : PAIN – Pulling Tugging Crying when lying on the affected ear Absence of pain indicates rupture of Tympanic Membrane – ear drum Lab Data : OTOSCOPY – revealed – reddened, bulging tympanic membrane
Nsg Dx : PI :
Infection Sensory – Perception Alteration
Treat Infection (antibiotics – 7-10 days) – if does not heal – possible MYRINGOTOMY
Hx Teaching : RIGHT POSITION while feeding
RETINOBLASTOMA S/S :
congenital tumor of the retina; genetically transmitted; autosomal dominant (common in MALE and FEMALE) LEUKOCORIA – “cat’s eye reflex” - whitish or grayish discoloration of the pupil Diplopia and or Strabismus
LAB DATA :
PE Opthalmoscopy
Nsg Dx :
Knowledge Deficit
Tx :
Surgery – Inoculation – done b4 age of 3 (chemotherapy – after surgery) Genticist
RETINAL DETACHMENT
GLAUCOMA
CATARACT
Aging (above 40)
Aging (above 40)
Aging (above 70)
Related to trauma
Common in Blacks Related to Trauma Familial Predisposition Rel. to Diabetes Rel. to Steroids Rel. to Chromosomal Abberation - those with D. Syndrome are prone
RF:
RETINAL DETACHMENT MP : There is separation of sensory and pigment portion of the retina – therefore it will allow fluids to go in between which give rise to OUSTANDING manifestation as: VISUAL FLOATERS – pt says: “I see light structures Curtain like Floating spots Cobwebs” S/S :
NO Pain Blurring of vision – because of floaters
Lab Data :
Opthalmoscopy
Nsg Dx :
Risk for Injury
PI :
Immediate Bed rest – AFFECTED SIDE TOWARDS THE BED – to allow the connection of DETACHED PART NO SUDDEN HEAD MOVEMENT AVOID reading (TV – ALLOWED) Prepare Pt for Surgery:
SCLERAL BUCKLING – use of laser to reduce inflammation and when inflammation subside, the detached retina portion will be attached thru scar formation.
POST SURGERY :
AVOID activity that requires BENDING, LIFTING, COUGHING; (No Bowling & shampooing of hair at sink)
REPORT SUDDEN eye pain – indicative of bleeding/ hemorrhage
GLAUCOMA MP :
INCRASE IOP due to obstruction in the outflow of acqeous humor or could be related to forward displacement of the iris. TREATABLE but NOT CURABLE If Obstruction related :
could lead to CHRONIC OPEN ANGLE.
If due to Forward displacement: can lead to ACUTE CLOSE ANGLE S/S : TUNNEL or Gun Barrel Vision – wherein there is loss of Peripheral Vision Halos around lights – rounded rings around eyes CLOSED ANGLE GLAUCOMA – (+) pain OPEN ANGLE GLAUCOMA – minimal or (-) pain LAB DATA: Tonometry – measures IOP (N12-21) – PAINLESS ACUTE G – as high as 25; Chronic G - as high as 50 Nsg Dx : PI :
Gonioscopy Opthalmoscopy Perimetry – measures visual field Risk for Injury
TO DECREASE IOP How: a. Administer MIOTICS (Pilocarpine, Tomolol, Diamox) – for LIFE - it decrease the production of ACQEOUS HUMOR – admin. At lower conjunctival sac
b. Prepare pt for Surgery : TRABECULOPLASTY – a new pathway was created for the passage of the blocked fluids; - Out-patient only (use of laser only)
TRABECULECTOMY – Hx Teachings : same w/ retinal detachment
requires hospital admission for 1-2 days
CATARACT MP : Opacity of the Crystalline Lense S/S :
Blurred Vision (Poor Color Perception) NO PAIN
LAB DATA: a. SLIT LAMP TEST – test for red light reflex (this reflex is absent in cataract pt due to presence of milky white lens)
b. Opthalmoscopy Nsg Dx : PI :
Risk for Injury
Prepare for SURGERY
CATARACT EXTRACTION –
Extra Capsular Cataract Extraction (ECCE) Intra Capsular Cataract Extraction (ICCE)
ECCE – removal of anterior part ICCE – removal of entire capsule
PHACOEMULSIFICATION - needle is inserted to lens and send vibration thereby crushing the cataract then suction it out
PERIPHERAL IRIDECTOMY – a whole is created then suctioning
Post Cataract Surgery – NO SEX for 4-6 weeks Health teachings – same w/ R. Detachment
MENIERE’S DSES
OTOSCLEROSIS (hardening of the ears)
RF :
High altitudes Aging Ototoxic Drugs
MP :
Cause by an imbalance of EndoLymphatic Fluids in the inner ear
S/S :
Aging
Overgrowth of the stapes
Sensori-neural hearing loss – since Inner ear was affected
Conductive Hearing Loss - since middle ear was affected
Tinnitus Hearing Loss + VERTIGO (only for M. DSES)
same
Lab Data:
Caloric Stimulant test
same
Weber’s test – lateralization of sound Rinne’s – bone conduction Audiometry (above test – use of TUNING FORK)
Nsg Dx :
Risk for Injury
PI :
SAFETY (to prevent pt from falling: bedrest or supine – danger of falls)
Sensory Perceptualalteration Establish Communication Surgery : STAPEDECTOMY – mobilization of stape
DIET :
LOW NA (AVOID – Alcohol & Caffeine containing food)
Meds : Effective :
AntiVertigo – Diamox, Bonamine (-) Vertigo/ Falls AVOID - driving PMS Sudden Head Movement
Post Surgery Hx Teachings:
AVOID – diving Small airplane Coughing Blowing of Nose Bending
TIPS FOR EENT
A pt who underwent cataract surgery w/ intraocular implantation is scheduled for discharge, the nurse shld instruct the pt to do w/c of the ff when pain occurs – notify the AP;
w/c Nsg Dx is considered a priority for a pt with Meniere’s Dses – Risk for Injury
a Tonometer is used for the purpose – to determine IOP;
Post Cataract Extraction : how shld the nurse position the pt – UNAFFECTED SIDE to minimize edema;
w/c of the ff is a common manifestation of Retinoblastoma – Cat’s Eye Reflex;
The parents of the pt w/ retinoblastoma must be referred to - GENETICIST
GASTROINTESTINAL GENERAL CONSIDERATION
Provide privacy Ask the pt when he 1st notice the S/S Eg. LIVER CIRRHOSIS – when did you notice that your eyes turns yellow?
PEDIATRIC CONSIDERATION
Introduction of FOOD: (shld be in order) Cereals Fruits Vegetables Meat Table foods Obtain child Dietary History Assess for over-intake of milk – poor source of iron (IDA)
REPORTABLE S/S Vomiting Abdl Pain (if more than 6hrs) – R/O rupture of the bowel Tarry Stool – indicates bldg (upper GI) Fever, Tachycardia, Dehydration – indicative of SHOCK Hypotention KEPOINTS… Bowel Sounds (check all 4 quadrants- N 5-35 bowel sounds/min) - to assess, use DIAPHRAGM of Steth – to listen for normal sounds BELL part of Steth – to listen for abnormal bowel sound Ex. “bruit” – abnormal vascular sound w/c indicate abdml aortic aneurysm
DIARRHEA/ AGE -
usually asso w/ NORWALK
(common in ship),
ROTAVIRUS and CLOSTRIDIUM DEFFICELE
MP : Passage of watery and loose stools (BEST judge in the consistency) S/S : Frequent stools Sign of DHN – sunken fontannels Poor Skin Turgor Absence of Tears (for more than 2 MONTHS old infant) Check for complication : Metabolic Acidosis If excess fluid loss, it will progress to shock – due to K loss (hypokalemia) LAB DATA : Stool Exam – to check for bacteria Nsg Dx :
PI :
Diarrhea Fluid Volume Deficit Place pt on ENTERIC ISOLATION PRECAUTION – while waiting for lab result
(handwashing & gloves ONLY)
CHALASIA
GERD
CONGENITAL WEAKNESS OF THE CARDIAC SPHINCTER
S/S:
vomiting - NON-BILE-STAINED
Hear-burn due to Reflux of Acid
Complication :
METABOLIC Acidosis BARRETT’S ESOPHAGUS
same same
- damage to mucosal lining of lower esophageal mucosa w/c can lead to esophageal CA
LAB DATA : Upper GI Series (Ba Swallow) Gastroscopy Esophagoscopy
do
do
do
Nsg Dx : Altered Nutrition Less Than Body Requirement Flds & E Imbalance PI :
Insure Adequate Nutrition Position: Place pt in UPRIGHT – to avoid vomiting (if BABY: use HARNESS or PRONE w/ HEAD UP POSITION)
Administer flds Antibiotics/ Antidiarrheals ( dosage: if less than 10 kg, therefore X100) Health teachings – crackers, juice, water Feeding : Thickened Prepare pt for surgery : NISSINFUNDOPLICATION – part of fundus will be sutured to esophageal area to tighten Effective: if (-) vomiting and(-) reflux and heartburn
POISONING INTERVENTION: a. CALL poison control center; b. MINIMIZE EXPOSURE – remove pt from the scene c. IDENTIFY the type of poison “if unknown substance was taken” – bring bottle or foil for proper identification TYPES:
CORROSIVE – “DO NOT INDUCE VOMITING” Management: NEUTRALIZE the poison If STRONG ACID – give WEAK BASE
(eg. ACID – give MILK)
IF STRONG BASE – use weak ACID by using vinegar
NON-CORROSIVE – induce vomiting by stimulating GAG REFLEX How:
a.
b.
Use fingers or tongue blade Syrup of Ipecac – administer w/ glass of H2O – make sure that all taken will be vomited – bec it is cardiotoxic (after 1hr – can repeat) dosage:
CHILDREN – 15 ML ADULT - 30 ML
CLEFT
LIP MP:
PALATE
Non-fusion of facial process
Non-fusion of Palative Processess (soft & hard)
(congenital)
(congenital)
Nsg Dx : Altered Nutrition Risk for Aspiration Body Image Disturbance PI :
Nutrition Safety Prepare for Surgery
Surgery : Chiloplasty
Palate Uranoplasty
- for 10wks old 10 lbs 10gms/hgb 10,000 WBC
- if child is 15-18 mos
Post Surgery:
CRYING shld be minimize – bec it will put pressure at suture line; LOGAN BAR/ BOW – it decrease tension at suture line; ELBOW RESTRAINT – prevent child from touching the suture line; FEEDING DEVICE – C CLIP – use dropper, C PALATE – use Breck Feeder/ cup Refer pt to: SPEECH THERAPIST, AUDIOLOGIST & PSYCHOLOGIST
PYLORIC STENOSIS -
-
congenital hypertrophy
(“kumapal”)
of the pyloric sphincter (bet stomach & intestine)
S/S :
•
PROJECTILE VOMITING
(INITIALLY, NON-BILE STAINED but eventually it PROGRESSESS TO bile-stained)
If sitting : 4-5 ft If lying down : 1 foot Feeding should be thickened then AFTER FEEDING, place to RIGHT SIDE LYING SEATED at car seat – to facilitate the entry of food from stomach to duodenum • •
OLIVE-SHAPE MASS VISCIBLE PERISTALTIC MOVEMENT – usually from L to R of the abdomen – w/c can lead to DHN
LAB DATA : Ba Swallow – (+) “string sign” NSg Dx :
Altered Nutrition Fluid Vol Deficit Fld and E imbalance
PI :
Nutrition Surgery – FREDET-RAMSTEDT or PYLOROMYOTOMY
CELIAC DISEASE -
GLUTEN –INDUCED ENETEROPATHY
– incision at pyloric sphincter
MP :
Genetic predisposition Life-time disorder Intolerance to GLUTEN
OUTSTANDING S/S : Malabsorption Syndrome-crisis Abdl Enlargement – this can be triggered by INFECTION & Fld and E imbalance Anorexia Anemia - there will be SEVERE DHN LAB DATA :
Diagnostic Test : GLUTEN CHALLENGE – 3-4 mos – give gluten rich food And if there is malabsorption, therefore (+) CDses
Nsg Dx :
Altered Nutrition
PI :
Dietary Modification :
AVOID GLTUEN RICH FOOD : ALLOWED :
Barley, rice, oats, wheat
Rice, cereals, corn, soy beans
Commercially prepared cakes are made of wheat – AVOID Ok or allowed: if pt say “I will prepare a homemade cake” AVOID : spaghetti, macaroni, sausage, luncheon meat, hotdog
HIRSCHPRUNG’S DISEASE MP :
(AGANGLIONIC MEGACOLON)
Absence of parasympathetic nerve fibers in a portion of a colon dilation, abdominal distention and pellet-like or ribbon-like stool. Patient – meconium ileus & constipation – HALLMARK SIGN
LAB DATA : BA Enema Nsg Dx :
Altered Ellimination
Diet :
High Fiber Increase fluids
Tx :
Give Enema
Meds :
Laxative Surgery – SOAVE Surgery – resection with end to end pull through
INTUSSUCEPTION MP : There is telescoping of a part of a colon which leads to inflammation and edema
S/S :
“sausage-shape mass” Abdominal distention “Dance sign” – the R lower portion of the colon becomes empty Vomiting : BILE-STAINED Constipation LAB DATA : Ba Enema: if for DIAGNOSTIC : it outlines the area involve if for THERAPEUTIC : it reduces intussuception by means of hydrostatic pressure Nsg Dx :
Constipation Altered Elimination
Diet :
Inc. Flds. High Fiber
Tx :
wonder drugs – steroid surgery
TRACHEOESOPHAGEAL FISTULA (TEF) MP : Failure of the esophagus to develop as a continous process Types :
AF1 AF2 AF3 AF4 AF5 AF6
-
esophagus NOT connected w/ abdomen/stomach esophagus attached to trachea (when pt eat, it goes to the lungs) stomach connects w/ trachea stomach & esophagus connected stomach, eso and trachea are connected separated properly
Atresia – “narrowing” Fistula – connection S/S :
Excessive Drooling – danger in aspiration (avoid glucose water as initial feeding – use sterile H2O instead.)
Coughing, Chocking Cyanosis LAB DATA :
Lateral Neck Xray – to check the esophagus
Nsg Dx :
Risk for Aspiration
PI :
Safety Airway Keep child NPO – just give pacifier
Tx :
(if feeding OK – use sterile H2o instead NOT GLUCOSE)
Surgery
TIPS FOR GASTRO – PEDIA
w/c of the ff signs if manifested by a child post tonsillectomy needs to be reported – FREQUENT SWALLOWING;
a child who has had several episodes of diarrhea is likely to develop – metabolic acidosis;
in relation to dx of p. stenosis, w/c of the ff actions of the nurse is important – weighing pt daily for wt loss;
w/c of the ff will the nurse expect to observe in a child who loss fluid due to diarrhea – flushed dry skin;
the most appropriate feeding device for a child post cleft palate – paper cup;
the priority nsg care for a child on NPO is – offer a pacifier regularly;
a common manifestation of pyloric stenosis is – visible peristaltic wave;
the priority nsg dx for a pt w/ rotavirus infection is – diarrhea;
w/c of the ff is expected in a child suffering from celiac dses – intolerance to gluten
PEPTIC ULCER RF :
Stress Smoking Salicylates or NSAIDS Helicobacter Pylori Zollinger-Ellison Syndrome (gastinoma) – tumor of the stomach – GASTRIC
ESOPHAGEAL
due to increase HCL acid
DUODENAL
RF :
same
same
MP :
Weakened Mucosa Common in Female Below 65 Inc risk for CA
Excessive HCL Acid Common in Male 65 yo & above
OUSTANDING S/S: PAIN – aching, burning, gnawing PAIN – 30mins – 1hr post meal PAIN at daytime Pain relieved by vomiting
2-3hrs after meal Nightime Pain relieved by eating Also related as hyperacidity
HEMATEMESIS (vomiting of blood) - severe bleeding – “shock”
LAB DATA :
GASTRIC Analysis (diamox blue – urine) Gastroscopy BA Swallow HgB Hct Nsg Dx :
PAIN
PI :
Relief of Pain
Meds :
ANTACIDS:
Maalox – it NEUTRALIZE HCL Acid; RANITIDINE - it DECREASE HCL Acid; SUCRALFATE - it COATS the GIT
NO ASPIRIN Diet :
BLAND DIET – NO SPICY, fried, raw fruits and vegetables
(EXCEPT: avocado, banana & pineapple)
GASTRIC SURGERY
VAGOTOMY PARTIAL GATRECTOMY – Billroth I (BI) and Billroth II (BII) TOATAL GASTRECTOMY
BI – gastrodoudenostmy – duodenum and stomach BII – gastrojejunostomy – stomach and jejunum COMPLICATIONS:
PERNICIOUS ANEMIA – due to decrease INTRINSIC FACTOR w/c came from stomach; DUMPING SYNDROME (occur usually for
10-12 mos post surgery)
– due to rapid emptying of the stomach and stimulation of gastro-colic reflex GASTRO-COLIC REFLEX – is usually due to increase CHO INTAKE in the diet - NO PANCAKE, NO UPRIGHT SITTING AFTER MEALS
S/S OF Dumping Syndrome :
Diarrhea Diaphoresis Dizziness/drowsiness
Management: NO FLUIDS after meals – instead in between meals DIET: High Fats – because it delays the emptying of the stomach LOW CHO Lie down – after eating
INFLAMMATORY BOWEL CONDITION ULCERATIVE COLITIS
DIVERTICULITIS
CROHN’S DSES (Regional Enteritis)
RF : With familial Predisposition Common in those LOW FIBER Diet Related to Genetics Smoking as Protective Effect Common in Aging Common in Obsessive-Compulsive Or Stress Related or to “perfectionist” MP : Inflammation @ large Intestine Inflam @ L Intes. – Specifically @ recto-sigmoid colon at DIVERTICULUM S/S :
Inflam of small & large intestine
same
same
DIARRHEA
(15-20x/day) bloody mucoid
diarrhea & constipation
3-4x/day
FEVER
(+)
(+)
(+)
CRAMPY ABDL PAIN LLQ (Rigidity (REPORT ASAP) –sign of colon rupture) LAB DATA:
BA ENEMA Colonoscopy Stool Exam
Nsg Dx :
PAIN Altere Elimination: Diarrhea
PI :
Relieve Pain Meds:
Steroids
LLQ
RLQ
Anticholinergic Antidiarrheals Antispasmodic DIET :
Low Fiber and Low Residue – for Ulcerative and Chron’s Diverticulosis – High Fiber/residue – allowed: vegetables Low residue – (no vegetables)
SURGERY :
Colostomy – irrigate Ileostomy – no need for irrigation
Characteristic of N Colostomy
–
REDDISH or PINKISH EDEMATOUS MOIST N elevation from skin: 2.5 cm Diameter : 5cm
When to empty colostomy: when 1/3 – ½ full (EMPTY DO NOT CHANGE) When to change C. Bag : 48hrs or 3x a wk BEST TIME TO DO COLOSTOMY CARE – at home, while in the bathroom STOP colostomy irrigation if patient (+) ABDOMINAL CRAMPS
HEMORRHOIDS MP
Varicosities of the ANAL SPINCHTER
RF PREGNANCY PROLONGED STANDING PORTAL HPN – hepatic enceph and liver cirrhosis
GRADE I II III IV
Small Area Large Area – reduces spontaneously Entire Area – manual reduction Entire Area – irreducible
TYPES INTERNAL H – above the spinchter EXTERNAL H – below the spinchter
S/S
Pruritus Pain Bleeding
LAB DATA
Sigmoidoscopy Proctoscopy P Exam
Nsg Dx
Altered Elimination
PI
Diet :
High Fiber Avoid Spicy
PAIN – use SITZ BATH (48 degree C – temp of H2o) - emerge up to pelvic area with ice pack at head to prevent dizziness STOOL SOFTENER SURGERY
PANCREATITIS -
AUTODESTRUCTION OR AUTODIGESTION of the pancreas
RF
#1 Alcoholism #2 autoimmune High Fat Diet Biliary Dses
SS
PAIN @ peri-umbilical area or epigastric that radiates to peri-umbilical area
GREY TURNER SIGN – pain w/ bluish discoloration at flank area; CULLEN’S SIGN – pain w/ bluish discoloration @ umbilicus NAUSEA & VOMITING SHOCK – as complication LAB DATA
Elevated Serum Amylase (N56-190 u/L that normalize in 2 wks)
Nsg Dx
PAIN
PI
Relieve PAIN Meds: DEMEROL – DRUG OF CHOICE AVOID MORPHINE – it causes more pain bec it will causes spasm to the spinchter of oddi
DIET
LOW FAT AVOID alcohol
CHOLELITHIASIS
CHOLECYSTITIS
Combine or usually come together in a pt
Stone in gall bladder
Inflammation of the G. bladder
RF
Fat Female Fertile Forty flatulence
same
S/S
R UQ Pain radiating to R shoulder or R Scapula – usually precipitated by FATTY INTAKE GI S/S – NAV diarrhea and Jaundice URINE: dark colored STOOL : “clay-colored” or grayish – alcoholic stool
LAB DATA
Increase AMYLASE, WBC, FATS Increase Liver Fnx test USG
Nsg Dx
PAIN
PI
Relief of Pain meds : DEMEROL diet: LOW FAT surgery :
1) LAP. CHOLE – 4 small incision, CO2 insufflation 2-3 days after – discharge pt and back to ADL 1 WK after – pt can lift weight 2) CHOLECYSTECTOMY – R SUBCOASTAL - complication: “Pneumonia” – report rusty-colored sputum hx teaching: TURNING, COUGHING, DEEP BREATHING
HEPATITIS MP
Inflammation of the Liver
TYPES A
B
C
D
E
Infectious
SERUM
POST TRANSFUSION
DELTA HEPA
ENTERICALLY-TRANSMITTED
Fecal-oral
bld, body flds
Non A & B
Post Hepa B
Fecal-oral
2-6 wks
6wks-6mos
70-80 days
6wks-6mos
(Hepa A & B Combination
STAGES OF HEPA B
PRE-ICTERIC - 1-2 days : S/S NAVDA – NO jaundice yet; ICTERIC - 2-4 wks w/ jaundice; POST ICTERIC - 2-4 mos s/s subside
Lab data
Increase Liver Funx Test (Inc AST/ ALT) Hepa A – Inc HaV Hepa B – HbsAg
Nsg Dx
Infection Alt Skin Integrity Body Image Disturbance
PI
Tx for Infection a. Meds : HEPATOPROTECTORS DIURETICS b. Diet : High Calorie Low Fat Isolation : A & E – Enteric B, C, D – Universal
COMPLICATION Liver Cirrhosis
LIVER CIRRHOSIS - scarring of liver tissues TYPES LAENNE’S
BILIARY
Due to alcoholism
CARDIAC
Due to biliary Disorder
POST NECROTIC
due to CHF
due to Hepatitis
S/S – are related to 3 FUNXs of the LIVER
MANUFACTURES :
bile, immunoglubolin, & clotting factors
METABOLIZES:
CHO, Fats, CHON, Alcohol and Drugs
STORES :
Vitamins & Minerals
Signs and symptoms
a. b. c. d.
pt prone to bleeding; malnutrition – no cho metabolize edema – due to fld retention (bec of dec albumin) Flds & e imbalance
LAB DATA
Increase Liver Funx Test Liver Biopsy
Nsg Dx
Risk for Injury Fld & E imbalance Fld Vol Excess Altered Nutrition
PI
SAFETY HOW?
Meds:
Diuretics – due to fld retention ANTIHPN – due to portal HPN Clotting factors : Coagulants – give Vit K (to avoid bleeding)
Diet :
LOW CHON or CHON to Tolerance Or High Biologic Value CHON – good quality CHON (eg poultry products)
SURGERY :
Liver Transplant
COMPLICATIONS:
a. HEPATIC EBCEPHALOPATHY – accumulation of ammonia – toxic to brain s/s:
PERSONALITY CHANGES DECREASE LOC or irritability/ restlessness
DRUG OF CHOICE : Neomycin, Lactulose - facilitate excretion of ammonia by acidifying the colon - common s/e : DIARRHEA
b. ASCITIS – accumulation of fluids at the abdomen s/s :
wt gain Increase abdl girth – “I cannot button my pants anymore” (fluids)
management: abdominal paracentesis – aspiration of fluids from the peritoneum - complication: chance for infection & shock pt preparation:
#1 instruct pt to void; #2 position: sitting the evaluate the WEIGHT, ABDL GIRTH & REPSIRATION
effective if : Pt decrease wt of 5 lbs and decrease or N RR
c. BLEEDING ESOPHAGEAL VARICES – DUE TO portal HPN Lab data
Sengstaken Blakemore Tube – 48 hrs inflated, scissors at bed side (Balloon Tamponade) - effective if (-) hematemesis
TIPS GASTRO – ADULT A pt w/ appendicitis was admitted, of ALL the ff written orders, w/c shld the nurse prioritize – Administration of Antibiotics; w/c statement if made by a pt w/ cirrhosis is a risk factor for having the disease – “I drink 2 glasses of alcohol /day”; which of the ff indicates a ruptured appendix – absence of pain;
ff subtotal gastrectomy, the nurse shld expect gastric drainage for the 1st 12 hrs to be – reddish brown; the priority nsg care post common bile duct exploration – preventing hypostatic PNA;
w/c question during nsg assessment would confirm the Dx of L Cirrhosis - how long have you noticed the white in your eyes turns yellow;
the priority nsg dx for a pt w/ Hepa B – altered Nutrition
the priority nsg dx for for pt w/ acute pancreatitis – Altered nutrition less than body requirements
NEUROLOGY DECORTICATE – abnormal FLEXION DECEREBRATE – abnormal EXTENSION Opistotonous – “back arching” GENERAL CONSIDERATION When assessing the neurological system, pay attention to the ff:
#1 LEVEL OF CONSCIOUSNESS #2 BEHAVIOR #3 REFLEX When assessing MUSCULO SYSTEM:
#1 Range of Motion #2 Joint Stiffness #3 POSTURES
PEDIATRIC CONSIDERATION a. Check for bowel and bladder funx – indicates neurological maturity 15-18 months – START BOWEL TRAINING 2 yo – start bladder training b. Assess for their habits “security blankets” – ex. Stuff toys, mother wallet Associate mother’s time w/ child activity (children has NO DEFINITE TIME) Ex. Your mom will be back after you have eaten your lunch.
c. Assess for presence of URTI – could be sign of Meningitis, Hemophilus influenza, Otitis Media d. Assess child for S/S of anxiety -
bed wetting nail biting (N up to 4 yo) head banging excessive thumb sucking
e. CONTUSSION – more severe, fatal and could even lead to death CONCUSSION – jarring of the brain, “na-alog” w/c could lead to s/s of LOC in 24-48 hrs DECORTICATE – abnormal flexion which indicates damage to the cortex s/s :
#1 Decrease LOC #2 widening pulse pressure (increase systolic BUT diastole is N) #3 Convulsion & seizures ABOVE ARE S/S OF INCREASE ICP.
DECEREBRATE – more serious - abnormal extension w/c indicates damage to brain stem
GLASGOW COMA SCALE EYE OPENING (4)
4 3 2 1
– – -
VERBAL RESPONSE (5) 5– 4–
OPEN SPONTANEOUSLY OPENS TO VERBAL COMMAND OPEN TO PAIN 2 NO RESPONSE 1 SCORE OF 3
:
SCORE OF 15 Score of 8
INCOMPREHENSIBLE NO RESPONSE
6 5 4 3 2 1
– – – -
OBEYS COMMAND LOCALIZES PAIN WITHDRAWS FROM PAIN INAPPROPRIATE 3 - DECORTICATE RIGIDITY DECEREBRATE RIGIDITY NO RESPONSE
NO response (DEAD) – Doctor will the one to pronounce :
:
-
ORIENTED CONFUSED
MOTOR (6)
pt is awake 50-50, MONITOR THE PT
7 and BELOW
:
pt is COMA
CRANIAL NERVES I.
OLFACTORY :
SENSORY :
II .
OPTIC
III. IV. VI.
OCCULOMOTOR TROCHLEAR ABDUCENS
V.
TRIGEMINAL
:
SIGHT
smell -
Abnoxious smell Anosmia – no smell Perfume
– snellen’s chart – 20/20 usually by age 3-6 yo
Eye movement - 6 cardinal direction of gaze (if abnormal look for DIPLOPIA)
: SENSORY :
responsible for FACIAL SENSATION (to check, use cotton & needle and run across the cheek)
AND MOTOR :
ability of pt to chew
Reflex: CORNEAL REFLEX – (+) if both eyes can blink
VII.
FACIAL
:
SENSORY : and
VIII.
MOTOR
:
sense of taste @ anterior 2/3 of the tongue Facial Expression
ACOUSTIC or VESTIBULOCOCHLEAR
- Sense of hearing and balance
TEST : ROMBERG’S TEST - stand erect, close eyes, observe for balance
IX. X.
GLOSSOPHARYNGEAL VAGUS
SENSORY MOTOR
XI.
SPINAL ACCESSORY
XII.
HYPOGLOSSAL
– Posterior Taste 1/3 Of The Tongue
- swallowing and gag reflex
- motor movement of shoulder muscle
– TONGUE MOVEMENT
DUCHENE’S MUSCULAR DYSTROPHY (DMD) X –linked RECESSIVE (only mother transmit to SON) (-) Father
Mother (+ carrier)
Son - 50% chance Daughter as Carrier – 25% chance
DMD
Erb Duchenne’s Paralysis (EDP)
Klumpke Palsy (KP)
Related to Birth Injuries affecting the BRACHIAL PLEXUS – nerves at axilla portion HEREDITARY
EDP – upper plexus KP - lower plexus
w/c leads to paralysis. Prognosis : complete recovery in 3 months Treatment : splint and cast for 3 mos – leads to nerve
regeneration
X-linked RECESSIVE DIRORDER MP
characterized by progressive muscle atrophy w/c apparent in male at the age of 3
S/S
a) GOWER’S SIGN – inability to stand up - use arms to brace the body b) WADDLING GAIT - duck-like gait c) impaired mobility d) difficulty in running and climbing
COMPLICATIONs
Respiratory Paralysis – for young children Cardio-Resp. Arrest - for adolescent
LAB DATA
Muscle Biopsy PExam
Nsg Dx
Ineffective Breathing Pattern Impaired Physical Mobility
PI
AIRWAY (keep TRACHEO at bedside)
TX a. b.
Supportive - leg brace, crutches Refer parents to geneticist Target: Mothers or FEMALES – bec they are the source of transmission Ex. Aunt, Female Sibling, mothers, female members of the family – (bec transmission: X linked recessive)
CEREBRAL PALSY - Permanent, Fix (non-progressive) neuromuscular disorder characterized by abnormal muscle movement. Cause
Unknown
S/S
Exaggerated Reflexes Protrusion of the tongue or tongue thrusting Early pattern of hand dominance Back Arching Scissors-gait
LAB DATA
Neurological Assessment PExam
Nsg Dx
Risk for Injury Impaired Physical Mobility
PI
SAFETY a.
Leg braces
b. c. d.
Meds : Anticunvulsants, Muscle Relaxants Prepare child for SURGERY – release of TENDON OF ACHILLES – to promote mobility Refer child to :
PT – for gross motor movement – walking OT - for fine motor – to open a bottle of soft drinks
HYDROCEPHALUS NOT A DISEASE but a manifestation of an existing disorder
Related to ARNOLD CHIARI MALFORMATION
DANDY WALKER SYNDROME
there is ELONGATION of the BRAIN STEM or Medulla - characterized by ATRESIA of and it protrudes to Foramen magnum Foramen of Luschka & Magendie SIDE NOTES:
FLOW OF CSF (N amt : 100- 200 ml) – rich in glucose
From Lateral Ventricle it goes to Foramen of Munroe then to 3rd Ventricle then to Aqueduct of Sylvius then it moves to F. of Luschka and Magendie going to 4th Ventricle then it goes back to subarachnoid spaces of brain. S/S OF HYDROCEPHALUS
PROJECTILE VOMITING IRRITABILITY ENLARGED HEAD – N Head Circumference : 33-35 cm (chest circum: 31-35 cm) SEPARATION OF SKULL BONES SEIZURES
SUNKEN EYES – Can Progress To Bossing Sign MACEWEN SIGN – crack pot sound upon knocking the head
LAB DATA
CT Scan MRI PExam – focus on head circumference (tape measure – at bedside to measure H Circumference)
NSG DX
Risk for Injury
PI
SAFETY
Position
Semi Fowler’s – to prevent increase in ICP
Meds
Diuretics Anticonvulsants
Surgery
Ventriculo-Peritoneal Shunt – progressive procedures (AS CHILD AGE PROGRESSES, the surgery is revised)
SPINA BIFIDA
– failure of a PORTION of spinal cord to fuse
TYPES
SB OCULTA NO SAC W/ DIMPLE or TUFT OF HAIR
SB CYSTICA W/ SAC SUB TYPES: Meningocele – w/ sac that contains CSF and meninges; Meningomyelocele – CSF, meninges and portion of spinal nerves
LAB DATA
Amniocetesis – test for ALFA FETO CHON – if INCREASE – Neural Tube Defect If DECREASE – Down Syndrome CT SCAN PExam
NSG DX
Risk for Injury
PI
Protect the sac
a. b. c.
SURGERY
Position: Prone or side lying (NEVER SUPINE); Wet sterile gauze to cover the skin; DOUGHNUT ring
WITHIN 24-48 HRS
COMPLICATION
Bladder and Bowel Problem Paralysis of Lower Extremities
Post Surgery Complication
Hydrocephalus (tape measure- at bed side)
INCREASE ICP
ICP above 15mmhg (N 0-10) Mild elevation : 11 – 20 Moderate : 21 - 30 Severe : 31 and above
With the use of INTRAVENTRICULAR or SUBDURAL MONITORING DEVICE to monitor ICP RF
Hydrocephalus Space Occupying Lessions Brain Tumor Trauma
S/S 1. INITIAL: Behavioral Changes – irritability, restlessness, decrease LOC – drowsiness or pt becomes sleepy 2. Vital Signs Changes – widening pulse pressure DECREASE RR and PR INCREASE temperature 3. Vomiting 4. Monitor Abnormalities – decorticate, decerebrate
Nsg Dx PI
Risk for injury To decrease ICP
Head of Bed ELEVATED Evaluate Neuro Status – Glasgow AIRWAY Discharge Meds Instruction
Seizure precaution – DARKENED ROOM
Anticonvulsants, Steroids, Diuretics (mannitol – to dec amt of cerebral edema)
MENINGITIS Inflammation of meninges w/c could be related to the presence of bacteria esp the H. Influenza, and Neisseria Meningitidis disorder S/S of
MENINGISMUS Inflammation of meninges but WITHOUT infection Usually accompany w/ resp.
INC ICP + Kernig’s Sign – pain on extension of lower extremities + Brudzinkis - flexion of neck would lead to flexion of lower ext.
- sign of MENINGEAL IRRITATION
LAB DATA
Lumbar Puncture CSF Analysis
Nsg Dx
Infection Risk For Injury
PI
Safety Seizure Precaution Tx the Infection Type of Infcetion:
a. Bacterial Meningitis – respiratory of droplet precaution b. Viral Meningitis - enteric precaution MEDS
Antibiotics to AUDIOLOGIST
For Bacterial Meningitis - may cause hearing impairment - refer
REYE’S SYNDROME Non inflammatory, non recurring but TOXIC ENCEPHALOPATY and HEPATOPATHY (CNS)
RF
Presence of Viral Infection Use of Aspirin
TRIAD S/S
Fever Impaired Liver Funx Impaired Consciousness w/c could lead to convulsion
STAGES
I II III IV V
LAB DATA
Bleeding and Clotting Time Liver Biopsy Neurological Assessment
Nsg DX
Risk for Injury Altered Thought Process Altered Thermoregulation Impaired Physical Mobility
PI
Treatment – symptomatic – assess neuro status Bleeding – give Vit K AVOID ASPIRIN when there is VIRAL INFECTION
pt becomes lethargic confusion decorticate rigidity decerebrate rigidity seizure or coma
CVA/ STROKE MP
Decrease Oxygen to brain cells
TYPES THROMBOSIS EMBOLISM HEMORRHAGE INFARCTION
(LIVER)
RF atherosclerosis hpn obesity smoking stress age/ gender SIGNS & SYMPTOMS: 1. DEPENDS ON THE PROGRESSION
a. TIA – brief period of neurologic dysfunction that last less than 24 hrs (between episode, pt is N);
b. STROKE IN EVOLUTION – there s/s like: facial paralysis Muscle weakness - above s/s could last 2-3 days c. COMPLETE STROKE – there is FOCAL s/s if R side of Brain Affected – L Eye - R Face – L Body if L Brain – R Eye – L face – R body 2. RELATED TO LOBES
•
FRONTAL – if affected – PERSONALITY CHANGES
•
TEMPORAL - memory disturbances –
– BROCA’S AREA (expressive aphasia – mouth
opening);
WERNICK’S LANGUAGE AREA (choice of words, understanding - RECEPTIVE APHASIA);
•PARIETAL - DISORIENTATION – especially SPATIAL orientation; •OCCIPITAL - VISUAL disturbances
3. SIGNS AND SYMPTOMS INDICATIVE OF COMPLICATIONS Hemianopsia
loss of half of the visual field (eg. Pt consumes half of the food at plate);
Hemiphlegia
paralysis of one side of the body;
Emotional Lability Aphasia
“mood swing” Expressive – inability to find right words to say (damage to Brocka’s Area); - pt can say right words – mgt: picture board and Receptive - inability to understand spoken words (Wernick’s area) mgt: talk to pt slowly
Dysphagia
instruct the pt to swallow twice to prevent aspiration
LAB DATA
Increase Cholesterol
Diagnostic Test
CT Scan MRI EEG
Nsg DX
Unilateral Neglect – inability to care half of the body Impaired Physical Mobility Risk for Injury
PI
SAFETY Position
Semi-fowler’s Elevated
Meds
Antihypertensive Diuretics Antilipimic Agents Anticonvulsants Thrombolytics – if (+) thrombus – to dissolve clots Low Na and Cholesterol
DIET Activity
Range of Motion Exercises
Surgery
Craniotomy Infratentorial Cranio – FLAT Supratentorial - Semi-fowler’s
DISEASES OF NEUROMUSCULAR :
GBS • • •
Guillain Barre Syndrome (GBS) Myastenia Gravis (MG) Multiple Sclerosis (MS) Amyotrophic Lateral Sclerosis (ALS)
MG
Descending paralysis – start @ upper ext. NO gender related factor but could be related to viral infxn Reversible
Common in Male and Female Early onset : 20-30 yo (Female) Early onset : above 50 yo (male)
MP Inflammation that leads to destruction of Peripheral Nerves 90% w/c leads to: ASCENDING GBS “neurotransmitter” DESCENDING GBS Mixed Type GBS
Deficiency in ACTH Receptor Sites – Or Def. in ACTH –
ASCENDING GBS - #1 Clumsiness that eventually lead to
S/S Muscle weakness w/c begins at
face muscle weakness & resp. depression which
therefore, Diplopia and Ptosis – progresses to MASK-LIKE face which lead
to
respiratory depression (descending paralysis – start at face – “NO
telebabad”)
LAB DATA
CSF – Increase CHON
TENSILLON TEST – 5 mins
(to all neuromusco disorders)
Nsg Dx
Ineffective Breathing Pattern (ALL)
PI
AIRWAY (tracheostomy – bed side) – ALL
MEDS
Steroids
same same Neostigmine – ATSO4 - antidote
Avoid crowded areas : viral infection Refer to NEUROLOGIST, PULMOLOGIST and PT
MYASTHENIA GRAVIS COMPLICATIONS
• •
Myasthenia Crisis (MC)
- due to under medication or lack of meds;
Cholinergic Crisis (CC)
- due to over medication – overdose
Signs and symptoms of above complication: MUSCLE WEAKNESS – in MC due to ACTH Deficiency while in CC due to or as adverse effect of the drug Treatment : TENSILLON – effective in MC – it INCREASE MUSCLE STRENGTH Effect in CC – it worsens muscle weakness once given – give ATSO4 NEOSTIGMINE – for MC as TREATMENT
MULTIPLE SCLEROSIS Common among women – especially white There is destruction of MYELIN SHEET at CNS , therefore generalized muscle weakness Eg. “I know I will be eventually confined in the wheelchair s/s of generalized muscle weakness:
LAB DATA
FACIAL – diplopia Impaired Cerebellar Funx Ataxic Gait – “lasing” Impaired Sensation – NO HOT/COLD BATH Impaired Sensory Funx – impotence
#1 MRI – specific test for MS – it localizes the area of plaque formation or the area of
dyemlination
#2 CT SCAN
NSG DX
same with GBS & MG
DRUGS
STEROIDS Anticonvulsants – dilantin Muscle relaxant – Baclofen Bladder Stimulants – Urecholine (bethanicol)
HX TEACHINGS
AVOID : HOT COLD SHOWER Refer to PT: ROM Exercises
AMYOTHROPIC LATERAL SCLEROSIS (LON GAHRIG’S DISEASE) MP
Destruction of Upper and Lower Motor Neurons; Genetically Transmitted: AUTOSOMAL DOMINANT – common in Male & Female More Pronounce is DYSPHAGIA The muscle weakness – will eventually lead to RESPIRATORY DEPRESSION
LABDATA
CSF – Increase CHON EMG – “contract and relax” – needle insertion Muscle biopsy
NSG DX
Ineffective Breathing Pattern
PI
AIRWAY (tracheostomy) SUPPORTIVE Refer to Geneticist
SIDE NOTES:
DSES
A Recessive :
Cystic Fibro, Sickle Cell, Apalstic/Fanconis – either or both parents are (+) for trait NOT
A Dominant :
Retinoblastoma, ALS – either father or mother (+) for disease or trait
X Link Recessive : Hemophilia, Color Blindness, Duchennes Muscular, G6PD Dses – mother (+) trait NOT DSES and transmit to SON
SPINAL CORD INJURY Destruction of S. Cord related to TRAUMA TYPES
• • • • • PI
CERVICAL THORACIC LUMBAR SACRAL COCCYGEAL SAFETY
8 – most serious – quadriphlegia 12 5 5 1 - immobilize, surgery
LUMBOSACRAL AREA – if affected, therefore PARAPHLEGIA – bowel and bladder problem THORACIC
- paraphlegia + bowel and bladder problem
CERVICAL c1 – c4 C5 – C8
- incomplete or partial quadriphlegia - Complete quadriphlegia
LAB DATA
Myelogram CT Scan Xray
Nsg Dx
Risk for Injury Impaired Physical Mobility
PI
SAFETY a. b.
Immobilize the spine – side lying w/ pillows bet legs Surgery
COMPLICATIONS OF SPINAL INJURY : AUTONOMIC DYSREFLXIA – due to full bladder and bowel s/s : #1 INITIAL : HPN #2 Diaphoresis #3 slight fever what to keep at bedside: CATHETER - TO KEEP THE BLADDER EMPTY, BEC IF FULL IT WILL TRIGGER THE ANS
TIPS FOR NEURO •
A 10 yo is to undergo EEG, w/c comment made by a pt demonstrate that she understands the procedure – “I will wash my hair after the procedure”;
•
A pt w/ tumor of the frontal lobe will most likely manifest – difficulty in concentrating;
•
A pt w/ M. Sclerosis has urinary incontinence. To achieve voiding, w/c nsg care shld the nurse give – establishing regular voiding sked;
•
While interviewing a pt. w/ Myasthenia gravis, w/c of the ff statements confirm the dx – “I have difficulty in swallowing”;
•
A male pt w/ CVA is observed by the nurse to have consumed half of his meal, the PRIORITY Nsg Dx – Unilateral Neglect;
•
When taking care of pt w/ C4 Spinal Injury, w/c equipment shld the nurse keep @ the b.side – Urinary Catheterization Set;
•
The PRIORITY NSG DX for pt w/ Myasthenic Crisis – Ineffective Breathing Pattern
MUSCULO CLUBFOOT DEFORMITY MP
Congenital Foot twisted out of place
Types Talipes Varus – “inversion” Talipes Valgus – “eversion” Talipes Equinus – “tiptoe” LAB DATA Nsg Dx PI
PE Xray Impaired Physical Mobility Promote Mobility
#1 MANUAL MANIPULATION #2 SEREAL CASTING – every 1-2 wks til position normalizes #3 DENNIS BROWN SPLINT – 2-3 months CAST : assess for s/s of neurological damage: REPORT
Capillary refill – if more than 3 sec. EDEMA Skin Color/ nailbed
CONGENITAL HIP DISLOCATION MP
Maldevelopment of the Hips – that involves the acetabulum, head of femur or both
S/S
Extra Gluteal Fold – at affected side; Ortoloni’s Sign – (+) Click Trendelenburg Sign or Pelvic Dropping – Alli’s Sign or Galleazi’s Sign –
LAB DATA
Nsg Dx PI
when child stand in one foot toward the affected side, then there is change in length shortening of the affected leg
PExam Barlow’s Manuever – press leg downward – (+) click Ortolani’s – abduct leg sideward – (+) click Impaired Physical Mobility #1 Double or triple diaper – to keep legs in abducted position; #2 PAVLIK Harness - for 2-3 mos #3 Hip Spica Cast LAST RESORT NO ADDUCTION OF LEGS!
FRACTURES MP
Break in the continuity of the bone
TYPES
Open (compound) – bone tears the skin – therefore open: risk for infection CLOSE – skin intact
• • • • • • • S/S
AVULSION – tear in the tendon COMMINUTED - fragmented COMPRESSED – crushed IMPACTED – driven to each other DEPRESSED – pressed SPIRAL – goes around the bone GREENSTICK – incomplete #1 Deformity #2 Pain #3 Edema
#4 CREPITUS – sound created when two bone surface rob each other NSG DX
Impaired Physical Mobility
PI
MOBILITY – immobilize the fx a. Splinting; b. Casting – check for edema – elevate the affected areas; - check skin color – capillary refill time - check for presence of blood stained
c. After cast, - CRUTCH WALKING
2 point gait – indicated if both lower extremities has partial wt bearing; 4 point gait – indicated for partial wt bearing; 3 point gait - indicated if 1 leg is allowed partial wt bearing and the other one is N; swing through - when both legs need to moved past the level of the crutches swing to – when both legs need to be moved AT THE LEVEL OF THE CRUTHES
going upstairs – unaffected then crutch (goodleg – crutch – bad) going down – crutch then bad leg – then good leg
SCOLIOSIS MP
Lateral Deviation of the Spine
RF
STRUCTURAL – non correctible FUNCTIONAL - correctible
OUSTANDING S/S
Uneven Hemline; Uneven waistline; Uneven shoulder (+) Rib Hump Prominent Iliac Crest
LAB DATA
Bend Over test – instruct to touch the toes and note for rib hump Xray
Nsg Dx
Impaired Physical Mobility - child Body Image Disturbance - adolesence
TX
a. To decrease curvature – wear BOSTON or MILWAUKEE Brace – for 23 hrs/day except bathing b.
SURGERY – HARRINGTON ROD - LUQUE
HX Teaching Avoid :
Bending Jumping Rope Playing Tennis Trampoline
Allowed:
Brisk Walking Swimming Cheer Leading
OSTEOPOROSIS/ HUNGRY BONE
MP
Loss of Bone Density
RF
#1 smoking AGING IMMOBILITY MENOPAUSE – decrease Estrogen Secondary to Existing Condition – as secondary Hyperparathyroidism
S/S
PAIN Dowager’s Hump Short Stature Progressive Decrease in Height
LAB DATA
Decrease in Calcium Bone Densinometry Bone Scan Xray
Nsg Dx
SAFETY
How?
DIET : High Ca especially 4 those with – OSTEOPOROSIS - spinnach - seafoods - sardines ACTIVITY : Partial Weight Bearing (NO SWIMMING) – jumping rope - bicycle reading - brisk walking MEDS : Ca Supplement - alendronate Fosomax – SIT UPRIGHT AFTER
ARTHRITIS RHEUMATOID
GOUTY
OSTEOARTHRITIS
Common
FEMALE
MALE
MALE/FEMALE
Affected Part
Upper Extremities
Lower Extremities
wt bearing joint
MP Chronic, systemic inflammation of connective tissues Synovial joints and joints of Upper extremities
S/S
PAIN Inflammation Morning Stifness
Stages of Rheumatoid A.
STAGE 1 – no Disability STAGE 2 – with Interference To ADL STAGE 3 - with major compromise of funx STAGE 4 - incapacitation ULNAR DRIFT
SWAN NECK DEFORMITY
LAB DATA
Decrease HgB Increase ESR
Nsg Dx
PAIN Impaired Physical Mobility
PI
Relief of Pain a. Warm Bath; b. MEDS : ASA - Antiinflammatory STREROIDS c. exercise: ROM
GOUTY ARTHRITIS MP
Metabolic disorder of purine w/c leads to deposition or uric acid at joints site: THE GREAT BIG TOE
S/S
(+) PAIN – usually aggravated by pressure (+) Inflammation -
above s/s affects the LOWER EXTREMITIES
LAB DATA
Increase Uric Acid
NSG DX
PAIN Impaired Physical Mobility
PI
Relief of PAIN Meds : Allupurinol, Probenecid Diet : Low Purine/ Purine Restricted: AVOID : Organ Meats SEAFOODS Alcohol ALLOWED: Cheese (EXCEPT fermented and Aged)
Increase ORAL Fluid Intake
OSTEOARTHRITIS A degenerative joint disease that involves the weight bearing joints – elbows & knees S/S
PAIN – NO inflammation Bouchard’s Nodes (distal) Heberdene’s Node (proximal)
LAB DATA xRAY Nsg Dx
PAIN Impaired Physical Mobility
PI
Weight Control
Health Teaching
Hot or Cold Compress
ASA Trunk Assistive Device (cane)
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) Autoimmune multi system dses characterized by inflammation of connective tissues JOINT CARDIOVASCULAR CNS OUTSTANDING S/S
: : :
(+) pain, (+) morning stiffness; (+) chest pain; (+) s/s of dec LOC, Irritability, Headache
BUTTERFLY RASH
(also present in pt in PROCAINAMIDE TOXICITY)
LAB DATA
Increase ESR
Nsg Dx
PAIN Altered Tissue Perfusion Risk For Injury
TX
Symptomatic/ Supportive – meaning, treat available s/s
Drugs
Steroids
TRACTION PRINCIPLES
T – rapeze bar R – equires free hanging weights A – nalgesic C – iculation monitoring T – emperature monitoring I - nfection prevention O – utput and input monitoring N – utrition S – kin Assessment
TIPS FOR MUSCULO
the priority nsg care for the pt w/ bucks extension traction shld be – ensure that the traction applied to the affected leg is always attached to the weight;
pt in russel’s traction is being taken cared of by the nurse, it would be necessary for the nurse to intervene if – the pt feet are pressed against the foot board;
a pt is using CRUTCHES for the first time, w/c action reflects a need for further instruction – the pt bears his/her wt with his/her axial;
a pt on buck’s traction of the R femur ask the nurse how he can possibly move around. What can the nurse advise the pt – you can hold on to the trapeze bar while moving;
w/c of the ff can possibly indicate the presence of abnormality in an adolescent – uneven hemline – scoliosis;
when assessing an infant, w/c of the ff needs to be reported – extra gluteal folds;
post spinal fusion –ROBAXIN –is given for w/c of the ff purpose muscle spasm;
a child has hip spica cast upon discharge, w/c statement of the father indicates further instruction – “ I will hold on to the bar bet his legs to help move him”
INTEGUMENTARY SYSTEM Burn – triage : face and perineum (priority)
BURNS Traumatic injury to the skin brought about by : FIRE CHEMICALS PROLONGED EXPOSURE TO SUN ELECTRICAL CURRENT HOT H2O CLASSSIFICATION:
- to decrease
According to Damage
2ND DEGREE
PARTIAL THICKNESS – FIRST DEGREE
EPIDERMIS
EPIDERMIS & PART OF DERMIS
Pain Redness
Redness Blister Formation
Eg sunburn
pain
THIRD DEGREE
4TH DEGREE
FULL THICKNESS
SUB Q FATS MUSCLES LEATHERY APPEARANCE NO Pain
SUB Q FATS MUSCLES & BONES CHARRED APPEARANCE No Pain
MINOR
MODERATE
PARTIAL TICKNESS
less than 15%
15-25%
FULL THICKNESS
NONE
<10%
MAJOR 25% >10%
RULE OF 9 – CHECK NOTE day 9 page115
BURN TRIAGE Priority : Burns of FACE PERIMEUM UPPER & LOWER EXT Burn related to Child Abuse Chemical – Fire THINK:
R escue A larm C onfine the Fire E xtinguish the Fire
PRINCIPLES OF NSG CARE FOR BURN PTS:
B – reathing – Airway U – rine output monitoring R – esuscitation of Fluids N – utrition S – ilvadene Ointment
DIET
DAT (High CHON, Ca, Vit C)
Complication
FIRST 24HRS – SHOCK 72Hrs - INFECTION
Pt Preparation :Bed Craddle
Fever
LYME’S DISEASE
caused by BORRELIA BURGDORFERI dog ticks
Rocky Mountain
(deer ticks)
Dermacentor/ Variabilis –
3-30 days
or Dermacentor Andersori (wood) 2-3 wks
s/s :
Fever, Pain, Chills, Rashes
RASHES: Bull’s Eye Rash or Rounder Rings At moist body parts
Generalized rashes
Complications Cardio, Musculoskeletal and CNS - which can lead to paralysis TX
Avoid wooded area – “have you been to the woods?”
PI
Vaccination Use long sleeve Remove ticks w/ twizers – upward straight motion
Meds
Chloramphenicol Tetracycline
DERMATITIS DIAPER (contact) Peak patients S/S
ATOPIC ECZEMA
(adult)
: During infancy – 9-12 mos Due to prolonged exposure to urine, soap & excreta
Cause : Hereditary Prone to asthmatic
:
RASH + scaling,
RASH
Crusting Pruritus or itching Viscicles Management: Hydrate the skin w/ cold compress Meds: Benadryl (antihistamine)
ROSEOLA
RUBEOLA
RUBELLA
Exanthem
MEASLES
GERMAN MEASLES
Causative Agent INC PERIOD
Herpez Virus
Unknown
10 -20 days
s/s RASH
Measle Virus
Rubella Virus 14 -21 days
FEVER and RASH
Non Pruritic Rose pink – begins w/ trunk
Begins w/ face & downwards
Face & downwards
Progressing outward
With KOPLICK’S SPOTS 3 C’s : Coryza Cough Conjuctivitis
+
same
MANAGEMENT: (to all types) Bed rest Antibiotics Antipyretic
C Agent I. Period
SYPHYLLIS
GONORRHEA
T Pallidum
N Gonorrhea
10-13 wks
HERPEZ Zoster
Simplex
2-7 days Vericella Zoster Virus
Abdominal
Genital H
Herpes Simplex Viruz
Oral Herpez
2-12 days vesicle
Steroids
Around the mouth
Inner thigh Buttocks Genitals
Acyclovir Cervical Ca – complication of Herpez
Annual pap smear
TRICHOMONIASIS
MONILIASIS/CANDIDIASIS
Caused by TRICHOMONAS Vaginalis
Albicans
Both are STDs Charac of discharge : Greenish/ Yellowish With FOUL ODOR
WHITISH-CHEESELIKE discharge
Inc Period
2 – 5 days
Druf pf Choice
4 – 20 days Flagyl
Amphotericin
TIPS
A nurse admits 8yo brought by her mother. Upon assessment, the nurse finds rounded rings of rash. This is indicative of – lyme’s dses;
During the immediate 24hrs pot burn, w/c of the ff is the priority – administration of fluis;
A pt tells the nurse that he notice small blisters on his private parts. This is indicative of – HERPEZ
A pt with CA of the cervix was admitted with the ff data: w/c one indicates a possible risk factor – previous tx for herpes;
w/c of the ff indicates effective tx of gonorrhea – (-) purulent discharge;
a pt is diagnosed w/ herpes zoster, w/c of the ff is the priority nsg dx – PAIN;
w/c of the ff is indicative of CHLAMYDIASIS – burning on urination
CANCER Cause RF
Unknown Theory of USE - Overuse, Underuse, and Abuse Smoking :
Lung, Bladder and Laryngeal or Oral CA
RACE
Jewish – Breast Blacks - Cervix and Prostrate Whites – Testes
:
PARITY :
Nulliparity – breast having baby after 35 yo Multiparity – cervix
DIET
High Fat and Low Fiber – CA of Colon Spicy – Ca of Prostrate
:
Raw – Ca of Stomach LABDATA
Screening Exams Male: a. Testicular Self Exam – mothly – begins age 16 yo- target are high school Female: a. Pap smear – at age of 18 (if sexually active) - anually b. Breast self exam – beginning age 20 – monthly c. Mamography – baseline : 35-40 yo : AFTER 40 yo – once every 2years After age 50 – annually BOTH MALE AND FEMALE
Nsg Dx
Digital Rectal Exam Sigmoidoscopy STOOL FOR OCCULT BLD
Initial If pt is TERMINALLY ILL If pt has some wishes or Unfulfilled needS :
: :
40 and above – ANUALLY ANUALLY after age 50yo Annually after age 50 yo Knowledge deficit HOPELESSNESS
Powerlessness
Nsg Care Principles : C hemotherapy – target cells : those rapidly dividing cells; A sess Body Image N tuition/diet : high CHON, well balance C aution pt on s/s E xercise R est COMMON S/S LARYNX LUNGS STOMACH BREAST OVARIAN CERVICAL PROSTRATE COLON Hodgkin’s Dses TESTICULAR
change in VOICE or Hoarseness changing cough or smoker’s cough (productive) dyspepsia a lump or a discharge complains feeling of fullness or indigestion “bleeding” elevated acid phosphatase, nocturia change in bowel habits painless enlargement of lymph nodes crytorchidism, spongy testes or lump (N – smooth unequal)
TIPS FOR CANCER
w/c nsg dx is a priority for a pt undergoing chemotherapy – SOCIAL ISOLATION;
when undergoing chemotheraphy, w/c solution is used for mouth care – HYDROGEN PEROXIDE;
w/c of the ff is an appropriate diet for pt undergoing chemo – bland diet;
the most common sign of Breast Ca is in – upper outer quadrant;
pt w/ CA of esophagus will manifest – DYSPHAGIA
TIPS FOR
PSYCHE
A pt w/ chronic depression is to undergo ECT, the purpose is to – relieve the symptoms of depression;
A nurse shld assess the pt w/ ALZEIMER’S DSES for possible change in – orientation;
A pt w/ bipolar episodes is ready for discharge when – she can comply with units activities;
The nurse would suspect that the child is a victim of abuse if he – keeps quiet while an IV is inserted;
w/c of the ff situations reflects an increase in self-esteem of an abuse child - when he ask the nurse for a plastic cup to drink;
the initial care plan for a pt with Anorexia Nervosa would require the pt to – remain in public place 1 hour after meals;
where shld the nurse put the pt on early alcoholic withdrawal – well-lighted room near nurses station
TIPS FOR OB-GYNE
A Mother Is Crying Besides her baby, she said “I feel so sorry I couldn’t hold her” – let her stroke the baby;
6wks pregnant woman ask the nurse about the signs of pregnancy – w/c one is expected at this time – frequent urination;
the nurse notes mirror image in the fetal monitor – this could be related to FETAL HEAD COMPRESSION;
which of the ff is related to trauma – ABRUPTIO PLACENTA;
A nurse is caring for a woman in first stage of labor, she is timing the duration of contraction – she is correct when she times it from the beginning of one contraction to the end of same contraction
TIPS PEDIA
w/c of the ff is expected by 6mos of age – sits w/ minimal support;
the most appropriate toy for 18 mos old child – carriage w/ a doll;
the appropriate room mate for an 8yo girl w/ leukemia is – 6 yo with hemophilia;
in a 3yo child – w/c of the ff shld the nurse assess during admission – special words used for objects and routines;
w/c of the ff is appropriate way of administering pre-op meds to 4 yo child – ask the child where she would like the injecvtion to be given
Paralysis of Lower
