021290 Gapuz reviewer

1NCLEX REVIEW – GAPUZ REVIEW CENTER (31 JANUARY – 17 FEBRUARY 2005, PICC, City of Manila) DAY 1 (31 JANUARY 05) STEPS IN PASSING        Have a Right Attitude THINK POSITIVELY … have a Fresh Start KNOW what YOU WANT and HOW TO GET IT OVERVIEW OF ESSENTIAL CONCEPT TRY OUT Focus assessment 7 habits of SUCCESSFUL EXAMINEE MOSBY – growth and development LIPPINCOTT – care of the Elderly and Communicable Disease DIGOXIN – monitor the creatinine… “ the TV DOESN’T look good to me” (DIGOXIN TOXICITY – nausea/vomiting, abdl cramps) Olive = butter CK LDH – normalize 1 – 3 days after MI - 10 – 14 days ATRIAL FLUTTER – SAW TOOTH PROCESS OF ELIMINATION 2  consider MASLOW’s H of NEEDS  consider the COMPLICATION whether ACUTE ALWAYS prioritize CHRONIC  ABCs  SAFETY FIRST  NSG PROCESS – MMR VACCINE – only vaccine for HIV pt. Pt on HEPARIN – APTT (N 30-40sec), therefore if INCREASE – bleeding 2. TODDLER – falls 3. SUPRATENTORIAL craniotomy – semi fowler’s position INFRATENTORIAL – flat in bed 4. 5. SCATTER RUGS – osteoporosis pts. TRIAGE ; burns, open fx – “SHOCK” Things NOT TO BE DELEGATED by RN: Assessment, Teachings, Evaluation POISON - nursing action in order : #1 CALL poison control center # 2 MINIMIZE EXPOSURE of pt to poison – pull him/her away from the poison # 3 IDENTIFY the poison Pt 50y/o and GENTAMYCIN – s/e tinnitus, vertigo, ototoxicity, oliguria Pt with Rocky Mountain Fever – exposure to dog ticks Lyme’s Dses – deer ticks LITHIUM CARBONATE – for ELDERLY : N level NOT more than 1.0meq/L ADULT : N .5 – 1.2 meq/L HEPA B diet : low fat, increase CHON DOWN SYNDROME – large tongue – feeding problem – poor sucking (infants) SAFETY PRINCIPLE 1. when can a child USE ADULT SEAT BELT? - if the infant is 40 lbs and 40 inches in height seat belt location in car: BACK CENTER SEAT - mammogram – once a year. Pt with PKU – LOW PHENYLALAMINE DIET (NOT phenyl FREE). – therefore LOW CHON PSYCHE PATIENTS 1. remember to stick to unit rules/policy – be consistent to pt. 2. encourage verbalization – “tel me how…..” 3. sound knowledge of cultural diversity seek help of interpreter 4. acknowledge pt feelings – “it seems….” “this must be difficult…..” 5. emphatize with your patients’s feelings “ I understand how you feel…..” CATARACT – CAUSES – aging and trauma MRSA (methicillin resistant staphyliccocus aureus) - USE GLOVES AND GOWN WHEN W/ PT 3 COMPLICATIONS: bubbling, breakage, blockage Nsg ALERT: TUBES 1. GROSHONG CATHETER HICKMAN BROVIAC - 2 lumen - 3 lumen - 1 lumen ALL requires Central Venous Access sites: cephalic, brachial, basilica and superior vena cava PURPOSE: For TPN Administration of Chemo Agents, Blood Products, Antibiotics COMPLICATION: Thrombosis and Bleeding 2. CHEST TUBES – Water Sealed Drainage Types: Anterior – w/c drains AIR Posterior - w/c drains FLUIDS Water Sealed Drainage : 1 bottle, 2 bottle and Three bottle system 1 BOTTLE emerge) : 2 BOTTLE emerge), : 3 bottle : 3 – 5cm of only (length of tube to be  NORMAL : BUBBLING is N in the 3rd bottle – it indicates that suction is ADEQUATE (if no bubbling STOPS in the 3rd bottle, meaning – inadequate suction)  ABNORMAL : if bubbling occurs at the 2nd bottle – indicates LEAKAGE – action, check sealed at air tight container and the pt and bottle connection. In case there BREAKAGE, have extra bottle and emerge tube ASAP to prevent entry of air and or may use forcep to clamp tube temporarily. If pt. ambulates, keep bottle LOWER than the patient. ABSENCE of OSCILLATION at the 2nd Bottle – indicates blockage TOWARDS THE BOTTLE - When MILKING the tubings. EMERGENCY EQUIPMETS AT BEDSIDE: xtra bottle,clamp, gauze 3. TRACHEOSTOMY TUBE to maintain patent airway for pt w/ neurological problems and musculoskeletal disorders. nursing care: First bottle – drainage bottle (no tube 2nd bottle - long rod 3-5cm FREQUENTLY USED 1st bottle – drainage 2nd bottle – water sealed 3rd bottle – suction bottle control 1. Suctioning – 10-15seconds - if (+) bradycardia, STOP - if accidentally dislodge, insert obturator to keep it open 2. AVOID: water sports – swimming 3. In changing ties – insert new one first BEFORE REMOVING old tie. tip of nose to earlobe to xyphoid process (for stomach) 2. PTCA – enlarge the passageway for bloodflow. I for lavage/gavage) .1 lumen Nursing Care for NGT: 1. Ribbon or ties @ side of the neck only to avoid pressure. 5.2 lumen (I for suctioning. infection and arrhythmia 5.wound drainage system . 4.if pt (infant) is having enteric coated meds. . 7. tip of nose to earlobe to XP + 7-10 inches for intestinal NGT 3. GASTROSTOMY TUBE (GT) PEG  both for NUTRITIONAL PURPOSES n/v GT – incision (abdomen to stomach) for pt (+) lesion at esophagus nsg care : report s/s of infection.2 lumen (insert then inject the mercury)  Cantor – for intestinal . Before feeding check for placement. accurate means to verify correct placement: ALWAYS consider Two checking criteria: ASPIRATION and Gurgling Sounds Report the following: If (-) or decrease drainage.1 lumen. 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. NASO GASTRIC TUBE – stomach and intestine (duodenum) Types:  Levine Tube – for stomach . request for change in form of meds   Miller Abbot – for intestinal (w/ mercury b4 injection) . abdl cramps. . for lavage (cleaning) and gavage (feeding) Salem Sump – for stomach .remove gradually 6.doctors the one who removes this. PENROSE DRAIN . (+) nausea and vomiting (+) abdml rigidity Characteristic of Gastric Residual: more than 50 mo and coffee ground. Before and After suctioning – hyperoxygenate the patient.4 4.  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. .place drainage bag at the level of t-tube (obstruction of t-tube – there will be excess drainage) 11.keep open to drain urine from kidney pelvis.to drain excess bile until hearing occurs .  HEMOSTAT – important instrument that shld be @ bedside for water sealed drainage. 12.inserted directly at the bladder wall .5 - provide adequate skin care PEG – incision at skin long term therapy Characteristic of drainage – 2-3 days after surgery (bloody to pinkish) – NO NEED TO REPORT THIS – it is expected 8.check if properly anchored 500 ml – N drainage in 24hrs. URETHRAL CATHETER – to drain urine. if report ASAP. T TUBE . . 10. THREE-WAY FOLEY absence of clot – effective SENGSTAKEN BLAKEMORE TUBE 3 lumen ( for esophageal balloon. 9. SUPRAPUBIC CATHETER – for genito urinary problem . HEMOVAC JACKSON-PRATTS (JP)  system  pressure. 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. BOTH used as close wound drainage suction BOTH system function on the system of (-) JP – compress the container before attaching to the drainage.never clamp because it can only hold 4-8 ml of urine. gastric balloon. . WHEN TO EMPTY: when its usually 1/3 to ½ full then RECORD the amount. addtl calories (300 cal/day) average of 2400 2700 b.sparingly MOST COMMON DIET  CLEAR LIQUID DIET (light can pass thru it. Galactogogues – increase production of milk  PEDIATRIC pt – by 4-6 mos – START iron supplement due to iron depletion and (-) extrusion reflex. meaning TRANSPARENT) . note dietary changes: a.source up the tree Low Na Diet : AVOID processed foods. vegetables.6-11 servings CHON .tuna. IRON : 15-30mg/day d. addtl of 10gms/day for CHON c. fruits.2-3 FRUITS & Vegs .cheese) e.6  BULB SYRINGE – use to clean the nares of pt with NGT (child)  To facilitate removal of air at lungs – purpose of water sealed chamber in 3 way bottle system. milk products and salty foods KNOW the serving: CHO .meat and table foods egg yolk (6mos). CALCIUM : RDA is 1000 then +200mg/day (broccoli. cereals. THERAPEUTIC DIET GENERAL CONSIDERATION  Know the DIAGNOSIS of the patient  Identify & incorporate the pt. 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) . dietary preferences  Instruct pt on what to avoid  For pregnant pt.3-4 FATS . 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. candy  RENAL DIET for kidney disorder (renal failure. AGN. peptic ulcer gastritis pureed foods/ blenderized foods soup  ACID ASH DIET . popsicle. preserved foods (cheese cake and custard)  HIGH FIBER DIET to prevent constipation.7 . milk products and BLAND DIET for peptic ulcer. inflammatory GI conditions AVOID: chemically and mechanically irritating foods such as fried foods. sea foods. renal. hemorrhoids & diverticulitis vegs.given to pt to relieve thirst. gelatin (strawberry).avoid fruits (anything you see in a tree)  PURINE RESTRICTED DIET - for gouty arthritis increase fluid intake AVOID: preserved foods. fresh and raw fruits & vegs (EXCEPT: avocado. alcohol. correct fld & electrolyte imbalance . & salty foods Low K . fruits and grain products  for cardiovascular dses. milk products. cardiovascular and renal dses ALLOWED: lean meat. vegs and fish AVOID : Sea foods.avoid processed foods. HIGH CARBO DIET for burns (about 5000 cal/day) grain products and poultry – to aid the healing SOFT DIET for inflammatory conditions: esophagitis. fld & e imbalance ALLOWED: fresh vegs AVOID : processed foods. Nephrotic syndrome) to maintain fld & e imbalance LOW CHON – avoid poultry products LOW Na . gizzard)  NA RESTRICTED DIET salty foods   LOW FAT/CHOLESTEROL RESTRICTED DIET for liver disorder. organ meat (liver. banana & pinya) and spicy foods with preservatives  tissues HIGH PROTEIN.given also to pt post-op ex: apple juice. fried foods. fruits. race Triage .-Surg – “abc” Psyche .45 PCO2 . corn. plums & pastries Ph – 7. wheat for PKU. ice cream. & corn 3 P’S .22 – 26 meq/L Ph  ALKALINE ASH DIET to increase ph of the urine indicated for acid stone ( uric acid stone.35 – 7.prunes. cheese. leche flan.pt evaluation system (prioritizing) APGAR SCORING Appearance pink Pulse >100 Grimace vigorous 0 1 2 pallor acrocyanosis all (-) <100 (-) grimace . oats. soy beans AVOID (LIFETIME): barley. Milk  -  GLUTEN-FREE DIET PHENYLALANINE DIET FULL LIQUID DIET opaque transitional diet from liquid ex : cream soup.safety first Fire . cystine stone) ex.35 – 35 HCO3 . pumpkin cake “ABGs” Uncompensated abnormal Partially compensated abnormal decrease Fully Compensated normal decrease no change increase or increase or Diarrhea – metabolic acidosis Vomiting – metabolic alkalosis for celiac dses ALLOWED : rice.8 - to decrease the ph of the urine indicated for pt w/ alkaline stone ex struvite ex. rye. 3 C’S – cranberry. cereals. milk. until age 10 and adolescence only AVOID : CHON rich foods (meat products – luncheon meat)  Compensatory Mechanism ATERIAL BLOOD GASES PRIORITIZING of case: Med. altered level of consciousness. minor burns. Fibrillation) 5. cardiac arrest. direction/communication supervision)  RN may delegate – feeding client. administration.G. airway compromise. 2.E -prioritizing 3.R. presence of vent. circumstances. person. lacerations. documentation CONCEPT OF DELEGATION  consider the competence of personnel  5 R’s in delegating (RIGHT task.I. pt bp 80/30 & mother died of CVA 1st priority : assess pt for addtl risk factor. multiple system trauma. routine medications and chronic low back pain DELEGATION do not delegate Assessment. Teaching and Evaluation do not delegate meds preparation. MI attack – 1st action : report ASAP (esp.A. cervical spine injury. eclampsia LEVEL 2 “urgent (stable)”  can be delegated (fever. dizziness) LEVEL 3  chronic/ minor illness (can be delegated) – dental problems. PT @ ER – sleeping pills overdose. routine vital sign (pt w/ no complications) and hygiene care TIPS ON PRIORITIZING 1.9 Activity flaccid flexion & extension Respiratory (-) lusty cry some flexion irregular T. MI ATTACK – enzymes to increase IN ORDER #1 myoglobin #2 troponin #3 CK #4 LDH . pt ask what procedure: Rn Action : notify the doctor 4. pt on NGT – check patency of tube LEVEL 1 “emergency”  severe shock. c. note for s/s of infection (when there is musty odor inside the cast) c. b. know your anatomy & physiology Post Liver Biopsy – R side lying – to prevent bleeding (during the procedure – L side lying). what to prevent or promote.  BURNS Position is FLAT or Modified Trendelenburg – to prevent shock. (pt say.report ASAP) . “I want to go home pain is gone”) POSITIONING FOR SPECIFIC SURGICAL CONDITION Positioning – independent nsg function know the purpose of the position a. Complication: infection Hiatal Hernia – upright to prevent reflux.10 RISK FOR INJURY – meniere’s dses INEFFECTIVE BREATHING PATTERN – myasthenia gravis ALTERED TISSUE PERFUSION – pt w/ complete heart block INEFFECTIVE AIRWAY CLEARANCE – pt w/ kussmaul’s breathing D  APPENDICITIS Unruptured : any position of comfort Ruptured : semi to high fowler’s position to prevent the upward spread of infection complication: peritonitis Ruptured appendicitis indication: pain decreases or go away. EXTREMITY Elevate the Extremity – to prevent edema (use rubber pillow) Nsg care: a. pruritus (inject air using bulb syringe) d. blood stained – mark and note (if increasing in diameter .   AMPUTATION complication: hemorrhage (keep tourniquet @ bedside) 1st 24hr – goal: to decrease edema – elevate the stump at foot part w/ the use of pillow AFTER 24hr – goal : to prevent contracture deformity (keep leg extended) CAST. capillary refill – N 1-3 seconds only (complication: altered circulation) b. SHOCK occurs w/in 24-48hrs (immediate post burn phase). to prevent or promote soothing. Position: to prevent subloxation (KEEP LEG ABDUCTED) with the use of wedge pillow or triangular pillow from perinium to the knees. hyperextension and prone – it causes hyperextension of the spine. b.   GASTRIC RESECTION to prevent dumping syndrome – usually for 10 mos only NOT LIFETIME disorder (post gastrectomy) position : LIE FLAT for 1-2hrs post meal LIVER BIOPSY before LB : supine or L side lying to expose the part during LB : .11 e. position: towards the affected side to stabilize the chest. Purpose: same   HIP PROSTHESIS FLAIL CHEST (+) Traumatic Injury – paradoxical chest movement – areas of chest GOES IN inspiration and OUT on Expiration LAMINECTOMY STRAIGHT “log-roll the patient” (3 nurses) – KEEP SPINE IN ALIGNMENT AVOID: hyperflexion.       CRANIOTOMY Types: a. . tingling sensation – indicate nerve damage  HIATAL HERNIA there is damage to esophageal mucosa what to prevent: gastric reflux therefore FEEP PT IN UPRIGHT POSITION. dumping syndrome : “flat” Infratentorial C .flat or supine.doafter LB : R side lying w/ small pillow under the coastal margin to prevent bleeding. Supratentorial C – semi fowler’s orlow fowler’s position – to prevent accumulation of fluid at surgical site. PNEUMONECTOMY  either L or R lung. AVOID: venipuncture. – during 1st 24hrs after the procedure. flexionextension (folding of clothing. vacuuming the house) Due to removal of axillary lymph node. avoid also gardening and hand sewing  RESPIRATORY DISTRESS Adult : Orthopneic position – over bed table then lean forward Pedia : TRIPOD – lean forward and stick out tongue to maximize the Airflow  RETINAL DETACHMENT to prevent further detachment. Ex. place pt on the R position. specimen taking. Position pt on the AFFECTED SIDE to promote lung expansion. 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. Post mastectomy Exercises: squeezing exercises.12  LOBECTOMY inside) removal of Lobe (N R lobe – 3. position pt on the L side AVOID: sudden head movement. . If operation is on the R outer of the R eye. keep pt on complete bed rest to prevent VEIN STRIPPING keep extremities extended then elevate the legs at level of the heart to promote venous return TIPS  liver biopsy is done on a pt. washing face.  AVOIDE SEX (may burn penis bec of the implant RADIUM IMPLANT OF THE CERVIX dislodge. blood pressure – ON THE AFFECTED ARM coz there is no more lymph node w/c predispose pt to bleeding. finger wall climbing. If operation is on the L inner of the R eye. place pt on the AFFECTED SIDE. turn the pt on his abdomen w/ pillow under the subcoastal area. DON’T GIVE FAKE REASSURANCE – “everything will be alright…. 1.” “you’re in the hands of the best” 4.13  a pt is about to go on thoracenthesis .how shld the nurse position the pt? – sitting w/ a arms resting on the overbed table. direct contact-Diptheria) TB OPTIONAL OPTIONAL (negative airflow room) .  after tonsillectomy – position: prone  best position for pt in shock – supine w/ lower extremities elevated THERAPEUTIC COMMUNICATION ISOLATION PRECAUTION RESPIRATORY OPTIONAL OPTIONAL Purpose : to isolate infection transmission (AIRBORNE: BEYOND 3FT DROPLET : W/IN 3FT) TYPE WASHING GOWN PRIVATE ROOM HAND GLOVE MASK STRICT (airborne dses.fowler’s position THERAPEUTIC PHRASES – it seems… you seem…. AVOID PASSING BACK – “I will refer you to….direct question. .”  to maintain the integrity of pt w/ hip prosthesis – abduction splints In GROUP DISCUSSION – nurse is just a facilitator – let the group decide.open ended question .” 3.for suicidal pt  when draining the L lower lobe of the lung – the pt shld be positioned on his R side w/ hip higher or slightly higher than the head.close ended – for manic pt and pt in crisis . DON’T ASK WHY – this put pt on the defensive 2. AVOID NURSE CENTERED RESPONSE – “I felt same too…” “I had the same feeling…. he/she channel are concern back to the group.  immediately after supratentorial craniotomy.  Essential when a pt w/ meningitis is kept in isolation: isolation precaution remains until 24hrs after initiating antibiotic therapy .  When discarding the contents of the bed pan use by a pt under enteric precaution – GLOVE IS NECESSARY. 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.14 CONTACT (direct contact – NOT AIRBORNE DSES) eX SCABIES ENTERIC X OPTIONAL OPTIONAL (fecal contamination) DISCHARGE X OPTIONAL (drainage: pus ex burn pt) UNIVERSAL X (AIDS.  A nurse is giving health teaching to the parents of child with scabies: family member must be treated. w/c nsg action require intervention: recapping the needle – this might prick your hand. head bands. HEPA b – TRANSMITTED BY BLD AND DODY FLUIDS) \ OPTIONAL TIPS:  When implementing universal precaution.  Preventing pediculosis in school age children: avoiding contact w/ hair articles of infected children like clips. they only want good news information of their condition NON INVASIVE – NO CONSENT needed  CONTRAST MEDIUM – check for allergy  For procedure requiring anesthesia – KEEP PT NPO B4 PROCEDURE DELEGATION and DOCUMENTATION Delegation – assessment. pt has the right to refuse procedure. monitoring and evaluation of treatment . 1. games and play to encourage participation DIAGNOSTIC PROCEDURES side notes: pt for IVP : assess for allergy (cleansing enema b4 the procedure) pt for KUB : no dye (don’t assess for allergy) schilling test : 24hr urine specimen USG : no consent required GENERAL CONSIDERATION  - EXPLAIN the procedure to the pt (initial nsg action) if not ready inform the doctor. if procedures require life threatening – they prefer to have male doctor. .they prefer same sex health care provider however. doctor the one who asked for consent  WITH CONSENT Check pt for CONSENT – if INVASIVE – TRANSCULTURAL CONSIDERATION HISPANIC PATIENT – women prefer same gender health care provider Obtain help of interpreter when explaining procedures – (except or don’t ask family members) For muslim patient .2HRS AFTER General anesthesia – keep NPO at least 8hrd after (check gag reflex before meals)  PEDIATRIC PATIENT – use flash cards.15 When local anesthesia used – NPO. Monitor for adverse reaction. then after challenge it increase to 155) KEYPOINTS FOR NURSES    Prepare the patient. early deceleration – indicates head compression (MIRROR IMAGE) b. variable deceleration – due to cord (image: U or W shape) and slowing of FHR can occur anytime.16 (cannot be delegated) BUT standard and changing procedures can be delegated ex. . NST is (+) if FHR increase at least 15 beats/min than the baseline. late deceleration – indicates placental insufficiency (REVERSE MIRROR IMAGE) mgt: L Lateral Recumbent Position. Treat Hypotenson c. monitor the baseline FHR then induce fetal movements by (HOW) : Documentation – type of treatment and any untoward reactions. Special Consideration and Interpretation DIAGNOSTIC TESTS (to evaluate FETAL GROWTH AND WELL-BEING)  DAILY FETAL MOVEMENT Purpose : to determine fetal activity by counting fetal movements – usually perform by pt himself N Fetal Movement 10-12 for 12 hr period (average: 1 movement/hr with average 3fm/hr)  NON STRESS TEST (NST) – correlates fetal heart rate w/ fetal movement a. Then check FHR and note the presence of DECELERATION (slowing of FHR) types of deceleration a.  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. b. 140 FHB baseline. – 24hr urine specimen and urine catheter collection. Administer O2. BABY is REACTIVE (good condition) and no need for contraction stress test/oxytocin challenge test – coz baby is OK and doing well. (ex. ring a bell feed the patient POSITIVE result means. Report complication to the doctor FRAMEWORK – includes the Purpose. then check FHR. NPO preparation: increase fluid intake (oral) NO consent needed If pt ask if it is painful: NO PAIN. . Pt shld have full bladder or can be done on the 3rd wk (34-36 wk) purpose: to detect fetal maturity (FLM) Get sample at chorion (by 10-12wks – thru monitoring of L/S Ratio N 2:1 The placenta matures. b. If DECRTEASE – down syndrome CHORIONIC VILLI SAMPLING – CVS . & presence of RH (eg. Trisomy 21) Incompatibility Done in 1st trimester can be done on the 2nd wk (14-16 wk) Extract blood at umbilical cord (can be done as early as 5th wk but . Down syndrome.but not recommended bec. meaning there is deceleration.provide data on placenta (age and location) gender of baby structural abnormalities position of baby . of danger then it is tested if it really comes can be done on 8-10th wk) abortion (assess pt age of gestation) from the umbilical cord (can be ULTRASOUND done on either 2nd or 3rd tri. indicates fetal jeopardy  AMNIO Purpose: to detect chromosomal Purpose : same w/ CVS Purpose: to check chromosomal Aberration aberrations. AMNIOCENTESIS – AMNIO PERCUTANEOUS UMBILICAL CORD BLOOD SAMPLING – PUBS CVS PUBS  BIOPHYSICAL PROFILE – CRITERIA to determine fetal well being w/ the use of 5 fetal breathing movement heart tone reaction to NST amniotic fld volume 2 2 2 2 2 points points points points points 10 points score below 6. - Upper USG – NPO Lower USG .for pregnant: site is lower abdominal USG types: a. get some sample) (if mother is (+) DM LS ratio is 3:1) This procedure also check level of alpha-feto Protein – if INCREASE – spina befida. baby is NOT OK coz there is decrease FHR and during labor he/she may stand the labor process.17 If (+) CST. nasal airflow and O2 saturation – N 95-98% below 85 – report ASAP GLUTEN CHALLENGE . c. DIAGNOSTIC TESTS (to evaluate pediatric patients) CARDIOPNEUMOGRAM – use to diagnose apnea of infancy – assess HR. RR. what to check – COMPLICATIONS of CVS.18 (+) Consent – invasive (+) Consent Bladder : Empty Gestation (+) Consent consider the Pt Age of (if age of gestation : is higher than 20wks and above : empty bladder.  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. AMNIO & PUBS: a.  USG DEVICE before Amniocentesis. if AOG is 20wks and below : full bladder  after amniocentesis w/c of the following manifestation if observed by the nurse on the patient that needs to be reported : bleeding.  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.  AMNIOCENTESIS – was done @ 35 wks gestation – purpose: to determine fetal lung maturity.  pt ask the nurse – what deceleration means – it refers to slowing of baby’s heart rate. b. infection bleeding abortion fetal death TIPS  EARLY DECELERATION – expected in the fetal monitor when there is fetal head compression. d. 19 detect presence of Celiac Disease (CD) intolerance to gluten. gluten free diet will be for life time) SICKLEDEX TEST ELECTROPOISIS HGB Purpose: test for sickle cell anemia Purpose: test for sickle cell anemia ORTOLANI’S TEST (OT) MANUEVER (BM) BARLOW’S purpose: test developmental dysplacia of the hip or purpose : same congenital hip dislocation Specimen : Blood : (blood + solution. abdl rigidity. abdl cramps. pt is given gluten rich food for 3-4 months the observe s/s of CD s/s of CD: distention test for pre-teen : “bend over test” – bend and touch the toe. abdl (if + for CD. steatorrhea. therefore + for SC Dses Test for TRAIT Test for Disease (+) if w/ click sound (lateral) (+) barlow’s click – press downward and w/ click sound POLYSOMNOGRAPHY or “sleep test” infancy - EEG is connected to pt when he sleeps Check the brain waves. HOLD CAFFEINE FOOD – 2days b4 test SCOLIOMETER - measure the degree or angle of scoliosis check for: (+) scoliosis if uneven hemline uneven waist more prominent iliac rest and scapula on one side presence of rib hump GUTHRIE CAPILLARY BLOOD TEST (GCBT) to detect PKU (in PKU there is absence of PHENYLALAMINE HYDROXYLASEPH) . check for apnea of preparation : No Special prep. therefore x-ray then scoliometer. (+) scoliosis – if presence of rib hump. if sickling of RBC Therefore TRAIT CARRIER (S or C shape RBC). if (+) TURBID Specimen : Blood : bld + electropoiesis. If absent PH. eyes and skin. At birth.N 60-100 bpm – check on # of QRS then divide it by 300 (k) ABNORMALITIES TIPS a. serum chloride test – N 90-110 meq/L (above 140 meq/L – (+) DIAGNOSTIC PROCEDURES I. therefore it will accumulates to brain and can cause mental retardation. (adult) N PH level .  pilocarpine – drug used for pt undergoing seat chloride test.  pt w/ PKU would more likely to have (+) result in gluten capillary bld test if there is – adequate CHON in the diet. atrial fibrillation – p waves “halos magkadikit.>2mg/dl (if 4mg/dl – indicative of PKU. atrial flutter – “saw tooth” flutter waves . Before test. no one will convert PH to Tyroxine. give chon rich food for 1-4 days before test. the skin becomes impermeable to Na. meaning cannot reabsorb Na and it accumulates outside of the skin). it is usually negative. ELECTROCARDIOGRAPHY – records the electrical activity of the HEART P wave – atrial depolarization QRS complex – ventricular depolarization ST . 8mg/dl – confirms PKU)  mother complains that her baby taste salty – which test is to be performed : sweat chloride test. so give CHON food first for 3wks then retest.20 Phenylalamine hydroxylase – is an enzyme that converts PH to Tyroxine – the one that gives color to hair.repolarization Rhythm – appearance of wave and distance Rate . Mother complain that her baby taste salty. (no discernable p waves) b. sweat chloride test – N 10-35 meq/L (above 40 meq/L– (+) b.  hgb electropoisis – test for sickle cell dses SWEAT CHLORIDE TEST to detect Cystic Fibrosis (in CF. PILOCARPINE – used in the test to induce sweating. Types: a. CARDIOVASCULAR A. PH came from CHON rich food.  9 yo pt has (+) result for sweat test – this indicates possible dx of Cystic Fibrosis. BLOOD CHEMISTRIES  SODIUM (135 – 145 meq/L) determines the ability of the heart to withstand equipment : threadmill & ECG nsg alert : check pulse and BP keep NPO an hr b4 the test NO Jewelries Addison’s Dses: hyponatremia (dec Na). SWAN-GANZ CATHETERIZATION 4 lumen for the ff CVP. CARDIAC CATHETERIZATION epinephrine shld be ready for any untoward reaction heart - it determine the structural abnormalities in the either L or R sided catheterization site: antecubital.21 c. t wave inversion MI . bleeding. Pulmonary Artery Pressure. ventricular – check on QRS (N . 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. brachial common complications: embolism.8-. femoral. 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.12) D. hypokalemia – “FLD VOL. ANGINA – st segment elevation. stress - STRESS TEST E. EXCESS” . hyperkalemia (inc K) – “FLD IMBALANCE” Cushing Syndrome: hypernatremia.. t wave inversion CORONARY ARTERIOGRAPHY medium - visualization of the bld vessels w/ contrast nsg alert: (+)consent check allergy to contrast medium increase oral fluid intake after to excrete dye B.st segment elevation or depression. Bld products. Pulmonary Capillary Wedge Pressure (PCWP). SGPT (ALT) N 8-20 u/L more on HEART (inc HEMATOLOGIC STUDIES RBC (4. if (+) kidney disorder AST (SGOT) .5 – 5 meq/L or 9-10mg/dl) Hyperthyroidism – inc CA Renal Calculi Formation – inc CA @ bld  LDH5 – 0-5% (for liver & kidney) LDH inc for MI for 3-4 days then it returns to N after 10-14 days GLUCOSE (80-120)  CPK or CK Higher than 140 – hyperglycemia (acidosis – may lead to ineffective breathing pattern and airway is the main problem) Male – 12-70 u/L Female .5)  - most sensitive index of kidney funx (increase BUN but N creatinine – do not report to AP) disorder  - increase creatinine – kidney failure or renal BUN (10-20 mg/dl) inc. for liver dses) for cardiac dses) G.10-55 u/L below 50 – hypoglycemia (pt prone to injury & altered thought process) dyas  Increase CPK 3-6hrs post MI then it normalize 3-4 Creatinine (.for liver (inc.N 8-20 u/L .5 – 5.22   LDH (40 – 90 u/L) POTASSIUM (3.5 – 5 meq/L) LDH1 – 27-37% (for heart – check for MI) Hyperkalemia : Addison’s dses Hypokalemia : Cushing Syndrome LDH2 – 17-27% (for heart – check for MI) Inc or dec in K PT RISK of INJURY LDH3 – 8-15% (for respiratory system) Pt w/ digitalis & diuretics – monitor for arrhythmia LDH4 – 3-8% (for liver & kidney)  CALCIUM (4.5 million) .5-1. 000) spontaneous bleeding occurs when platelet dec (pt also prone to injury) DOPPLER USG to detect the patency of bld vessels – arteries & veins esp of lower extremities. PT (11-12 sec) sec) PTT (60-70 sec) coumadin – check pt heparin – PTT monitor pt 4 bleeding monitor pt 4 bleeding APTT (30-40 HGB – male : 14-18 mg/dl Female : 12-16 mg/dl Dec hgb – anemia (nsg dx: activity intolerance) HCT . Pt may expect a sore feeling (PINK STINGED Report (+) stridor CHEST X-RAY to determine abnormalities of lungs and thoracic cavity. bld disorders like leukemia dec WBC – pt prone to infection inc WBC – hyperleukocytosis – (+) to pt w/ leukemia – risk for infxn PLATELET (150. non invasive.dec RBC – anemia – activity intolerance WBC (5-10 thousand) to detect presence of infection. tree or airway passages. NPO b4 & after Gag reflex return after 1-2hrs. to gather specimen for biopsy.determine the adequacy of hydration and the ration of plasma to the cellular component blood inc hct : hemoconcentration (nsg dx: fld deficit – dehydrated pt) dec hct : hemodilution fld excess  – – – – – SPUTUM) –   RESPIRATORY BRONCHOSCOPY visualization of b. ABSOLUTE CONTRAINDICATED TO PREGNANCY Check pt for radiation indicator Determine effectiveness of tx and whether pt is active or non-active  SPUTUM STUDIES .000-450. no preparation.inc RBC – polycythemia – risk for injury – complication CVA . 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. painless.23 .35-45% . .pink stinged EXHALE then INSERT mouth piece.blood streaked CHF/ PULMONARY EDEMA .aspiration of fld at thoracic cavity (for diagnostic & therapeutic purpose) position: DURING – sitting AFTER .(+) for immigrants.test for POSSIBLE TB EXPOSURE. color. .thru the use of incentive spirometer . LUNG SCAN .assess for bleeding. MANTOUX TEST . malignancy .24 to determine the gross characteristic of the sputum (refers to the amount. HOLD then EXHALE  . 10mm . .rusty BRONCHITIS .aspiration of tissues at lungs for dx of tumors. previously (+) pt.vital capacity (4-5 L of air) – refers 2 N amt of air that goes in & out of lung after maximum inspiration.affected or unaffected side Nsg alert: NO COUGHING & DEEP BREATHING – during the procedure – coz this may cause puncture of the lungs.(+) consent. BEVEL UP then read 48-72hrs after 5mm in duration – (+) for HIV. children below 3yo and for pt w/ medical condition – DM & Alcoholism 15mm . breath sounds & report for s/s of dyspnea . consistency and characteristic) TYPE OF SPUTUM PNEUMONIA TB PROCEDURE: BREATH iN.using PPD (purified chon derivatives) .with contrast medium.angle 10-15. multiple sex.to identify the presence of blockage in the pulmonary bld vessels. abnormal particles. Assess for breath sounds after.(+) for general population  LUNG BIOPSY . Complication: bleeding and pneumothorax  PULMONARY FUNCTION TEST . .gelatinous  Sputum specimen – sterile container  THORACENTESIS .assess for rxn to allergy .Viral – thin & watery Bacteria . d. space occupying lessions alcohol brain waves and seizures CONTRAINDICATION (same w/ ct scan BUT w/ addtl) a. keep epinephrine and or benadryl at bedside for emergency . (-) consent detect the ff: brain tumors. obese pt (more than 300 lbs). c. OBJECTS c. Measurement of blocked artery) NSG ALERT: (w/ or w/out dye)  CEREBRAL ANGIOGRAM involves visualization of bld vessels @ vein w/ the use of contrast medium. e. pacemaker.jewelries. lie still during the and “thumping nursing alert:  dietary modification: WITHOLD CAFFEINE – coffee and tea. assess pt for allergy.  WITHOLD 48hrs b4 the procedure : tranquilizers. d. anti-convulsant. sedatives.  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. alcohol CT SCAN MRI PET Use radiation to determine use electromagnetic field use gamma rays or positron electron tissue density to detect abnormality of tissue density to detect abnormality of tissue density. pregnancy. hip replacement e. (detect cancer and tumor) also to detect O2 saturation @ tissue. pt w/ unstable v/s (arrhythmic & HPN). b. pt w/ allergy to dye “clicking sound” will be heard & procedure lie still lie still during the procedure sound” will be heard NO METAL . bleeding Nursing Alert: a. pregnant pt. inc oral fld intake to excrete dye.25 CONTRAINDICATION III. monitor for signs of bldg. and to evaluate tx like CA Tx give more detailed impression (ex. b. physiology of psychosis. keep pt NPO. claustrophobia (give anti-anxiety b4) insulin pump. CONTRAINDICATED IN: pt w/ allergy..             LUMBAR PUNCTURE MYELOGRAM nucleus test for presence of slip disc or herniated porposus (HNP). EENT .26 - N amount: 100-200 ml Characteristic : Clear w/ glucose. b.  - water based – called AMIPAQUE oil base – called PANTOPAQUE  type of dye will determine the position of pt AFTER the procedure.   If water based. CSF has glucose. ALERT: Know the type of dye use: aspiration of CSF for assessment to check for infection or hemorrhage DURING : fetal or C-position : FLAT to prevent spinal headache Needle is inserted between L3 and L4 or L4 and L5 Increase fluid intake after. headache) CSF ANALYSIS Assess for the characteristic of CSF. 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. position: AFTER a. the HEAD OF BED ELEVATED. If oil based. IV. Na and H2O If REDDISH – hemorrhage If Yellowish – infection Ear licking w/ fluid – test if (+) glucose bec. to differentiate OPEN and close angle galucoma. place at mastoid bone or in teeth then…. Barium . non-invasive.27 CONDUCTIVE HEARING  LOSS TONOMETRY - to measure IOP (N 12-21) . therefore  - GASTRO INTESTINAL TRACT UPPER GI SERIES (Barium Swallow) xray visualization with contrast medium .Acoustic Neuroma  - GONIOSCOPY V. If BONE CONDUCTION IS LONGER. .swallow – milk shake like (use feeding bottle of pt) . if pt hear better in POOR EAR. Place tuning fork 2inches from the ear Problem would be SENSORINEURAL LOSS. To determine air and bone conduction If pt hears vibration better in GOOD EAR. Gastrografin – water soluble. therefore CONDUCTIVE HEARING LOSS SENSORINEURAL HEARING LOSS.refers to if AIR CONDUCTION is LONGER. SEVERE NYSTAGMUS – NORMAL MODERATE NYS .Minierre’s Dses NO NYSTAGMUS .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. use straw b. painless WEBER TEST RINNE’S TEST To determine lateralization of sound.Contrast Medium: a.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 . polyps and lesions. 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.28  - BARIUM ENEMA (for Lower GIT) involve rectal installation of barium. if Increase HCL Acid – therefore ZOLLINGERELLISON SYNDROME – (+) Gastric Tumor . if urine colors turns BLUE. - with contrast medium w/s is given thru IV  GASTRIC ANALYSIS analysis of gastric secretion like HYDROCHLORIC ACID Lower Level N : 2-5 meq/hr Upper Limit N: 10-20 meq/hr UPPER LIMIT YPES a. therefore (+) HCL Acid. therefore (-) HCL Acid if (-) HCL Acid at stomach (achlorhydia). 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. diverculosis. after. hepatic duct & common bile duct) – same with CHOLECYSTOGRAPY – but medium given orally. Fish and Horse Radish  CHOLANGIOGRAPHY visualization of biliary tree (includes. therefore Gastric CA. - ALERT: assess for allergy (epinephrine/benadryl) Post procedure: inc. - WITHOUT TUBE (tubeless gastric analysis) using DIAGNEX BLUE (specimen: urine). oral fld intake – to facilitate excretion of dye there is balloon catheter inserted @ anus then barium is instilled and pt is asked to roll-over at different position then xray is taken to detect: hemorrhoids. if urine (-) blue color. (+) Consent . invasive – (+) consent.NPO b4 .29 b. Tell pt that tere will be feeling of soreness a wk after the procedure Position after : R side-lying position  COLONOSCOPY visualization of colon to detect: inflammatory bowel condition Chron’s Dses Diverticulitis Hemmorhoids Tumor Polyps . NPO – tube insertion. dec BP Check v/s  ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP)  ULTRASONOGRAPHY upper abdl USG to detect abnormalities in the upper abdl area w/ includes biliary tree and Upper GI. WITH TUBE – with the use of NGT then aspirate - Things to report: s/s of SHOCK – inc PR. and ALERT: Check for Bleeding Time (N – 1-9 mins) Clotting Time (N – 10-12 mins) – because liver is highly vascular organ - WHEN NEDDLE IS INSERTED tell pt to: Inhale then Exhale then Hold Breath – to stabilize liver position - to visualize common bile duct and pancreatic duct. gel at abdomen and pt is NPO  LIVER BIOPSY aspiration of sample tissue from the liver to detect: Hepatic CA and Cirrhosis. painless.  ENDOCRINE GLUCOSE TOLERANCE TEST test. midnoc). therefore Diabetes ACTH STIMULATION TEST to detect presence of Addison’s Dses specimen: blood pt is given dose of ACTH (not nore than 40ug/dl) if still dec despite ACTH administration. therefore pt is suffering depression VI.   17 KETOSTEROID & 170 HCS use to detect the presence of Addison’s & Cushing’s Dses. Inform pt to have high CHO diet 2 days b4 the Addison’s – dec secretion of ketones Cushing’s – ince secretion of ketones Instruct NPO a day b4 the test (npo post Specimen: 24 hr urine Inc sugar level. therefore Adrenal Insufficiency – Addison’s Dses  - VANILLYLMANDELIC ACID TEST – VMA Test bi-product of CATHECHOLAMINE Metabolism epinephrine norepinephrine .30 . to provide measure of bld sugar level at blood. if despite dexa administration still increase adrenal hormones. a dose of dexa will suppress the release of adrenal hormones.clear liquid diet – 2days b4 the procedure position: Lateral or side lying position or L Lateral Sims  DEXAMETHASONE SUPRESSION TEST to detect endogenous depression – depression resulting thru endocrine disorder pt is given dexa then 24hr urine specimen is collected. note for s/s of bleeding .PIH. sea weeds) 7-10 days b4 and to include other diagnostic procedures that uses contrast medium (“NO” . kidney dses. amber s. coffee. – bec it may yield to false (-) result. ureter and bladder xray of the kidneys.025  - CYSTOSCOPY visualization of urinary bladder after : monitor I & O.uses contrast medium/ dye .  - CULTURE & SENSITIVITY RAIU  to detect infection prepare storage container KUB IVP . N 2-7 mg/dl / 24hrs – if inc. AVOID: vanilla containing food 3 days b4 test – ice cream. dec hypothyroidism AVOID: iodine rich-food (sea foods. to test for hypocalcemia and hypothyroidism – gather after meals VII.angiogram test). sea shells.  SULKOWITCH’S TEST detect amount of calcium excreted at urine.gather specimen b4 meals.31 abnormality: inc if there is TUMOR (pheocromocytoma) of Adrenal Medulla lower than 1.030 – diabetic mellitus (+) glucose – infection. cleansing enema in AM R E NA L URINALYSIS examine the gross characteristic of the urine urine amount : 30-60ml/hr color : clear. then inc. oral fld intake after . gravity : 1. if to test for hypercalcemia and hyperthyroidism . ureter and bladder .010 – 1.NPO POST MIDNOC. chocolates   pt is given iodine 131 then after 24hr followed by a thyroid scan inc indicates hyperthyroidism.xray of the kidneys. therefore tumor Urine maybe refrigerated if waiting to be examined.005 – diabetic insipidus higher than 1. DM (+) CHON .assess for allergy.NO SPECIAL PREPARATION NEEDED .benadryl or epinephrine at bedside for allergic rxn . lie still during the procedure. PAINLESS AND NON INVASIVE MUSCULO-SKELETAL ELECTROMYOGRAPHY  - ARTHROSCOPY . marrow (eg. (+) consent.KEEP TORNIQUET. to check if bladder respond to distention after installation of flds. monitor I & O VIII.  ARTHROCENTESIS to detect electrical activity of the muscle.visualization of joints . check for order of analgesic. MISCELLANEOUS BONE MARROW BIOPSY Leukemia) to check abnormalities at the b. apply cold pack    CYSTOURETROGRAM to check the patency of the ureter and bladder. aspiration of tissues at kidney for biopsy to - note for s/s of bleeding malignancy/ Ca malignant HPN kidney disorder to alternately contract and release the muscle as needle is inserted HOLD muscle relaxant b4 the test  aspiration of fluids at synovial space to detect abnormalities. . monitor I & O CYSTOMETROGRAM to evaluate the sensory and motor funx of bladder. c. b.32  RENAL BIOPSY detect: a. ICE PACK and ANALGESIC at bedside IX.  BONE SCAN detect rate of bone destruction or bone resorption for pt w/ osteoporosis. then NOTE for RATE of EXCRETION of VIT B12 (N – less than 40%).  ROMBERG’S TEST  check FUNX of CEREBELLUM. for pt w/ PERNICIOUS ANEMEIA.33 emergency  site : ILEAC REST (+) consent assess for bleeding sand bag at bedside (post procedure) – for use SCHILLING’S TEST specimen: 24hr urine test for VIT B12 deficiency.  RELEASED by destroyed or damage bones HETEROPHIL ANTIBODY TEST detect presence of IgM w/c is related to Epstein Virus infection Epstein Virus Infection – causative agent of infectious mononucleousis (“kissing dses”) to detect HEMOLYTIC DSES WITHOLD ALL MEDS – 24hrs b4 the test BENCE-JONES PROTEIN ERYTHROCYTE FRAGILITY TEST mgt: AVOID SHARING of utensils and glass  LYMES DSES SEROLOGY detect presence of BORRELIA BURGDORFERI – causative agent of lyme’s dses. and observe for inability to maintain posture (if pt is Swaying. If 100mg Vit b was taken – 60mg shld retain at stomach and 40mg will be excreted. therefore HEMOLYTIC ANEMIA (EX. therefore TUMOR at cerebellum) Treatment: tetracycline .  stand erect. pt is given oral VIT B12 then urine is collected. close eyes. SICKLE CELL)   detect presence of MULTIPLE MYELOMA (malignancy of plasma cells).     URINE UROBILINOGEN  use to detect the rate of RBC DESTRUCTION in a hypotonic solution (RBC Lifespan: 120 days) if lifespan of RBC >120 days. eg.  MRI is the primary diagnostic tool for multiple scelosis bec it promotes visualization of plaques at the brain. TIPS FOR DIAGNOSTIC PROCEDURE  2 moths old infant suspected of brocholitis is treated with oxygen therapy. 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.hold breath during the procedure upon insertion of the needle.  After liver biopsy. Which result indicates that tx was effective : 02 SATURATION OF 98%.  Staff nurse is observing a nurse caring for pt w/ cvp.34  A pt is to have an upper GI series – which statement shows that he understood the instruction given : “I will drink the dye”.  Pt is scheduled for liver biopsy. .  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”. What shld the nurse instruct pt to do during needle insertion? . w/c intervention is appropriate after the procedure: palpate the popliteal and pedal pulses. the catheter was inserted at the L femoral artery. a potential complication: bleeding.  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.  A mantoux test is (+) – if the nurse assesses w/c of the following: in duration.  In explaining to the pt about cystoscopy the nurse shld say : the bladder lining will be visualize.  Pt w/ coronary angiogram. LITHIUM – if above 65 yo. dose shld not more than 6mg/day c.  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. shld not 50 mg II. HALDOL – if above 65 yo.0mEq b. do not give to pt taking MAO  ONLY RN’s are allowed to administer (to include central line)  - VALERIAN sedative (used also as anti-anxiety agent) DAY 5 (8 Feb 2005) PHARMACOLOGY . may cause lead toxicity  - ECHINECEA use to boost the immune system.35 LPN’s – peripheral IV Line route. for pt. dose shld not more than 1. with cancer I.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. GENERAL CONSIDERATIONS  - ST JOHN’S WORT anti-depressant (it funx like MAO inhibitor). MEPERIDINE – if above 65 yo. EFFECTS – always consider bone marrow (“leukocytopenia – all PENIA”)  3 COMMON DRUGS – with patients over 65 y/o a. TRANSCULTURAL ASIANS – are stoicism attitude (they refuse meds if for the 1 time) st MIDDLE EASTERNERS . can cause staining of teeth. The following CANNOT be delegated: treatment. Photosensitivity (use sunscreen when outdoors)   LITHIUM – shld have inc. route. ANTIPSYCHOTIC major tranquilizer. documentation of meds IV. dosage and untoward reaction. NO HERBAL to lactating pt. C– HECK- THE CHECK PRINCIPLE lassification (FOR WHAT?) ow will you know that he meds if effective (evaluation) xactly what time are you going to give it lient teaching tips eys to giving it safely PSYCHOTROPIC I.s/e : diarrhea  ANTABUSE (dizulfiram) – most appropriate time to take meds : after 12hrs of alcohol free. NO HERBAL for those with severe kidney and disorder  Lactulose – given to pt with hepatic enceph to dec ammonia absorption . fluid in the diet III. 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) .36 - adverse effects – GI Irritation GINGCO BILOBA blood thinner. use to enhance bld circulation.  COGENTIN – to prevent pseudoparkinsonism (by decreasing muscle rigidity) TETRACYCLINE . administration. DELEGATION AND DOCUMENTATION Document all medical admin record: time. for pt w/ alzeimers CONTRAINDICATED to pt with bleeding disorders  - COMMON CONTRAINDICATIONS for HERBAL MEDS:    liver NO HERBAL MEDS for pregnant client. b.ANTIPARKINSONIAN CLIENT TEACHINGS:  – a. AST/ALT To prevent pseudoparkinsonism. administer ANTIPARKINSONIAN agents IA. c. BP. b. Dantrium  Assess SIGNS and SYMPTOMS of PSEUDOPARKINSONISM a. 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. LOOSENES OF ASSOCIATION – shifting of topic  hyperpyrexia and muscle rigidity this indicates NEUROLEPTIC MALIGNANT SYNDROME (NMS) drug of choice: Parlodel. Report ADVERSE EFFECTS of ANTI-PSYCHOTICS which indicates agranulocytosis fever body malaise sore throat chills in schizo there is increase dopamine. Therefore give dopaminergic. DOPAMINERGICS . therefore give antipsychotic to dec dopamine then dec dopamine causes pseudoparkinsonism. DELUSION – “FALSE BELIEF” b. L-Dopa Levodopa Levodopa-Carbidopa .hearing sounds c. HALUCINATION .37 ex. d. c. mask-like face or expressionless face pill-rolling tremors cogwheel’s rigidity or lead pipe rigidity  AKATHESIA – “restless leg syndrome” (I feel as if I have ants in my pants)  DYSTONIA  Avoid direct sunlight – because meds photosensitivity  Instruct pt to rise slowly – to avoid orthostatic hypotension Check: CBC. Signs & Symptoms: a. ex. urinary retention NOT urinary frequency decrease BP – rise slowly check BP. Tranxene  Effective: Decrease Anxiety. ANTI-ANXIETY minor tranquilizer decrease Reticular Activity System – center of wakefulness ex. Alcohol – it increase the depressant effect of the drug d.  When to give: AFTER MEALS.  Health Teachings: a. c. constipation – inc. III. ANTICHOLINERGIC - decrease ACETYLCHOLINE ex.38  Effective if decrease in tremors and rigidity within 2-3 days. ECG a. roughage at diet. palpitations – check PR. AVOID: Caffeine. e. f. side effects: blurred vision (no driving). IB. b. administer VALIUM separately – because it is incompatible with any drug – use different syringe. g. c. report ADVERSE EFFECT: PARADOXICAL REACTION – opposite of side effects b. Decrease Muscle Spasm (to pt w/ traction) Promote Sleep  B4 MEALS – because food delays absorption  HEALTH TEACHINGS: a. TRICYCLICS MAO STIMULANTS . check RR – it causes respiratory depression e. diazepam. II.  Health Teachings: dietary modification: AVOID CHON and Vit B6 . Danger of Dependency c. PR. check BP and PR b. ANTI-DEPRESSANT/MANIC a. Valium.bec it decreases drug absorption b. d. Librium. c. check for ORTHOSTATIC HYPOTENSION and PALPITATION. when to give: AFTER MEALS. dry mouth – suck on ice chips or hard candy. Benadry Cogentin   effective: if decrease tremors and rigidity. 39 d. SSRI PATIENT with DEPRESSION – there is DECREASE norepinephrine and serotonin . Tofranil.  directly stimulates the CNS. Parnate. . VEGETABLES COLA. it suppresses the appetite. TRICYCLICS – prevents the reabsorption of norepinephrine. Nardil and Marplan C. after MAO – 2 wks rest then can give ST JOHN’S WORT MAO INHIBITOR (MonoAmine Oxidase) prevents the destruction of NEUROTRANSMITTERs ex.  Check BP – the drug can cause HYPERTENSIVE CRISIS – occipital headache – “my nape is aching”  DEPRESSANT 2 WKS INTERVAL – when shifting ANTI – to avoid HYPERTENSIVE CRISIS ex . banana. aged and swiss) ALLOWED: cheese – cottage and cream. Elavil Effective: If adequate sleep (8hrs only) Increase appetite Avocado. it causes INSOMNIA – 6 Hrs b4 bedtime. Effective : if INCREASE SLEEP and APPETITE – STIMULANTS (Ritalin.40 A. cheese (cheddar. Dexedrine and Cylert) Give AFTER MEALS - Hx Teachings: Effective: Increase Appetite and Adequate sleep AVOID – TYRAMINE CONTAINING FOOD (1 day before FIRST DOSE and 14 days AFTER LAST DOSE) Best to Give: AFTER MEALS if b4 meals. CHICKEN LIVER SOY SAUCE RED WINE PICKLES Best given: AFTER MEALS Hx Teachings:  The INITIAL EFFECT 2-3 wks after FULL THERAPEUTIC EFFCET 3-4 wks ONSET EFFECT in a WK  AVOID : juice – because an acidic medium decrease absorption of drugs  REPORT PALPITATION and TACHYCARDIA and ARRYTHMIAS – adverse effects of TRICYCLICS  CHECK BP and ECG B. FRESH MEAT. Ex. give NOT BEYOND 2pm bec. - LITHIUM it alters level of neurotransmitters effective if DECREASE HYPERACTIVITY give AFTER MEALS Hx Teachings:  diet: High Na (6-10 gms) and High Fluid (3-4L)  Avoid activity that increase perspiration – Na & H2o.4 .sign of LITHIUM TOXICITY – Dug of choice: MANNITOL DIAMOX Hx Teachings: III. ZOLOFT.2 .5 – 1.1 ANTIMANIC    Lithium (lithane.  check BP and PR  - D.  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. THIRST and ATAXIC ..41 INSOMNIA shld be given in the morning – to avoid N Na – 3 gms. NORMAL LITHIUM LEVEL: ACUTE DOSE Below 65 yo mEq/L MAINTENANCE DOSE .8 mEq/L . N fluid intake 3L Basically. escalith) Tegretol Depakine/ Depakote A.5 – 1.  Avoid caffeine.0 mEq/L .6 – 1. Lithium is a salt COMPLICATIONS: growth suppression  provide intervals or intermittently to avoid growth suppression. Report also: Hx Teachings: SSRI (selective serotonin reuptake inhibitor) Ex. lithobid.5 mEq/L Above 65 yo . Prozac Adverse effects: DECREASE LIBIDO and Impotence s/e: GI Report the ff s/s (NAVDA) Nausea Anorexia Vomiting Diarrhea Abdl Cramps FINE HAND TREMORS progressing to COARSE HAND TREMORS.  Report S/S of Bone Marrow Depression – pancytopenia (dec RBC & WBC). . good muscle contraction) PROSTIGMIN – long acting – for treatment TENSILLON – short acting – only for 5 mins.gingivitis For ALZEIMER’s DSES Aricept ANTICONVULSANT (Tegretol and dilantin) Myasthenia Gravis – there is decrease or absence of Acethylcholine (ACTH) for seizures. effective: if (-) seizure given BEST AFTER MEALS (except for sedatives. wherein there is abnormal discharge of impulse in the brain action : IT INHIBITS the seizure focus and discharge ACTH is a neurotransmitter the delivers the order ex. Lactating.like valium) – MOST DRUGS THAT AFFECT CNS ARE BEST GIVEN AFTER MEALS TOO. – it increase muscle strength in 30 seconds (therefore.42 Lithium is effective with 10 – 14 DAYS before it will reach its therapeutic level.  Instruct pt to use SOFT BRISTTLED TOOTHBRUSH. ACTH. Increase chewing ability or able to chew food forcefully)  GIVE B4 MEALS or any activity. Kidney disorder . if dec cholinesterace and inc. instead of lithium use TEGRETOL. NSG ALERT:  Report GINGIVITIS.if above s/s are (+) to patient. Check : CBC – due to pancytopenia RBC.  Instruct pt to MASSAGE GUMS and frequent oral hygiene : Cognex (tacrine) and Therefore. DOPAKINE/ DEPAKOTE tegretol – a/e : alopecia CHOLINESTERASE INHIBITORS For MYASTHENIA GRAVIS : Prostigmin (long acting) and Tensillon (short acting) dopakine/ depakote . Brain to muscle to contract/move. the drug is given to inhibit cholinesterase in destroying ACTH (so. WBC and Platelet label CONTRAINDICATION OF LITHIUM:    Pregnancy. if muscle weakness disappear within 30 seconds – it is MYASTHENIA GRAVIS) Drug Action:  Increase muscle strength (ex. Therefore. diet of patient – no appropriate.RAPID ACTING :onset : 24 – 48 hrs Coumadin and Heparin .  Report s/s of HEPATOXICITY – RUQ pain of abdomen and JAUNDICE “INR” – refers to the upper limit of meds from N value to the maximum dose Antidote: ATSO4 – it reverses the effect of anticholinesterase  Check for LIVER FUNX TEST. TIL INR of 175).  Keep at bedside: endotracheal tube – for resp. NSG ALERT: monitor PTT (N 60-70 SEC. if more than INR .43  Meds is FOR LIFE.HOLD thromboplastin PRO THROMBIN FIBRIN (CLOT) COUMADIN – act as vit k dependent clotting factors HEPARIN – converts PROTHROMBIN to THROMBIN and FIBRINOGEN to FIBRIN . problem ANTICOAGULANT HEPARIN LOVENOX COUMADIN For ACUTE CASES of Manic Case MAINTENANCE or Chronic CASE FOR Heparin Derivatives Antidote: PROTAMINE SO4 Antidote: VIT K Antidote same w/ Heparin Given SubQ (Lower Abdl Fat) Oral Onset: 2-5 days COAGULATION PROCESS: Vitamin K dependent clotting factors THROMBIN COUMADIN FIBRINOGEN (maintenance case) HEPARIN Check PT (N 11-13 sec and INR 24 sec) Effective if (-) clot Give same time of day Report s/s of bleeding : Hemoptysis Hematemesis HEPARIN: AVOID – green leafy vegetables – bec it is rich in Vit K and will counteract the effect of anti coagulant. rate and rhythm QUINIDINE LIDOCAINE PROCAINE Ventricular arrythmia ANTIARRYTHMIC (quinidex. report CNS – confusion. CHRONOTROPIC Effect . check pt PR and ECG – waves. it affects the repo and depo of heart muscle CARDIAC GLYCOSIDES - increase force of contraction.nausea. Quinidine (quinam) Side notes: Health teachings: Characteristics of HEART MUSCLE: a. c. to maintain the balance in the Na and K pump give antiarrythmia because it decreases the automaticity of the heart. CONDUCTIVITY – ability to propagate impulses. EXCITTABILITY .force of contraction or strength of myocardial contraction.44 – NOT to dissolve clot (only as THROMBOLYTIC – meaning it prevents ENLARGEMENT and FORMATION of CLOTS) which causes arrhythmia.rate of contraction a. Chromotropic Effect – conduction of impulses. pronestyl) For VENTRICULLAR & ATRIAL Fibrillation repolarization – resting phase (k goes out) depolarization – stimulating phase (Na goes in) (therefore the depolarization and repolarization of heart muscle depends on Na and K pump. hearing loss and visual disturbances d. REPORT s/s of QUINIDINE TOXICITY – tinnitus. AUTOMATICITY . anorexia and vomiting b. d. And so. can be given together Give meds anytime. ataxia and headache GI . REFRACTORINESS – ability of t heart to respond to stimulus while in the state of contraction.) K – once it increase or decrease.ability of heart to initiate contraction.ability of the heart to be stimulated Inotropic effect . b. RASH – therefore SKIN TEST FIRST c. ANTIARRYTHIMICS Ex. - Antiarrythmia is effective if (-) arrhythmia. . .  Check BP and PR.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. AFTERLOAD – amount of resistance offered by blood vessels that heart shld overcome when pumping blood  Effective if NEGATIVE ANGINAL PAIN. K – shld be monitored when in this meds therapy (The heart contraction is regulated by Na and K pump. Calcium enters and it will result to a more increase force of contraction due to Na and Ca pump conversion.  Administered SUBLINGUALLY (+ burning sensation indicates drug is potent) – NO WATER because it will dilute the meds.  Report if there is persistence of pain.  Check PR – if BELOW 60/min (adult) – HOLD next dose. b.45 affects the automaticity and excitability of the heart muscle. if BELOW 70/ min (older child) – HOLD.  DOSES: 3 doses at 5mins interval. if BELOW 90. If K decreases. Digoxin Digitoxin : .  Give BEFORE any activity.5 – 2 ug/L : 14 – 26 ug/L Effects: (+) INOTROPIC – strengthen the force of contraction (-) CHRONOTROPIC – decrease rate of contraction DIGOXIN DIGITOXIN EFFECTIVE : it increase FORCE OF CONTRACTION same ACTION mins – 2hrs : onset : 5 – 20 mins Give after meals due to GI irritation same CLIENT TEACHINGS:  Report s/s of TOXICITY : NAVDA Xanthopsia – yellowish vision or greenish halos.  Keep meds in dark container (bec light dec potency). NITRATES (nitroglycerine) 30 don’t give if pt taking VIAGRA – it will result to FETAL HYPOTENSION EFFECTS: dilatation of coronary arteries and arterioles thereby resulting to DECREASE IN PRELOAD & AFTERLOAD. Decrease in Preload – decrease in the amount of blood that goes to the LV. PENICILLIN : antidote is EPINIPHRINE II. side effects: NAVDA + GI Irritation I. give meds anytime. for ACUTE ATTACK and PREVENTION of ASTMA EXPECTORANT (robitussin) stimulates productive coughing. tachycardia. effective: (-) infection. prevention. give ON EMPTY STOMACH – B4 MEALS. b. Hx teachings: REPORT rash. AMINOGLYCOSIDE (gentamycin) effective: (-) infection – give B4 meals. CREA (kidney funx test). cytomel) . TERBUTALINE – brethine) - check BUN. effective: if (-) bronchospasm. Hx Teachings: inc oral fluid intake (2-3L/day) – cytotoxic monitor kidney funx – I & O. effective : (+) COUGHING & SECRETIONS give ANYTIME. palpitation-PR. + NAV III. client teaching: meds can be diluted w/ NSS or Side effects: NAV + Rashes - if no side effects. report the ff: OTOTOXICITY: “I hear ringing in my ear” NEPHROTOXICITY : ”oliguria” NEUROTOXICITY : “seizures” BRONCHODILATORS (ex.46  Once the bottle is open. GIVE IN ARM – to prevent HEMMORRHAGIC Theophylline .N 10-20. effective: (-) tumor size. it decreases the viscosity of secretion. use the meds within 3-6 mos DO NOT REPORT THE FF: (expected s/s) Hypotension. Headache. check I & O (sign of nephrotoxicity) dilates the bronchioles or airways. Mucomyst cola. Driving) ANTIBIOTICS bactericidal. sideffects: – NAV + DIZZINESS or drowsiness – avoid activity a. facial flushing “why is my face red?” MUCOLYTICS (an antidote also for ACETAMINOPHEN TOXICITY) Ex. urticaria and “STRIDOR” – indicates airway obstruction. repeat dose in 1 hr that required alertness (ex. ANTINEOPLASTIC (adriamycin) CYSTITIS - for breast and ovarian CA. GIVEN in AM to decrease insomnia REPORT THE FF: insomnia. THYROID AGENTS (synthroid. Report sore throat. b. effective: if Inc in T3 and T4 and NORMAL SLEEP. and INCREASE SLEEP – indicates that pt is having HYPERTHYROIDISM. nervousness.late in the afternoon – B4 dinner .  PEAK OF ACTION (refers to – when patient becomes HYPOGLYCEMIA) REGUALR INSULIN Intermediate Long Acting . give b4 meals regularly. check phosphate level and renal funx test. pt always sleep.instruct pt to REPORT: muscle weakness in lower extremities – indicates HYPOPHOSPATHEMIA administer with glass of water.lunch time . check: instruct S/S OF HYPOGLYCEMIA – dizziness/ drowsiness difficulty in problem solving decrease level of consciouness cold clammy skin ALUMINUM HYDROXIDE GEL – antacid and it also dec phosphate level in pt renal failure. LUGOL’S SOLUTION) For GRAVE’S DISEASE or HYPERTHYROIDISM. effective: N Blood sugar (80-120) for DM Type 1 (insulin dependent).47 for HYPOTHYROIDSM. body malaise because meds cause AGRANULOCUYTOSIS. chills. stimulate pancreas to produce insulin. Diarrhea with metallic taste – sign of IODINE TOXICITY b. tagamet) ANTIDIABETICS (INSULIN) a. c. antidote for hypoglycemia – ORANGE ANTACIDS (amphogel. therefore give meds in AM – to avoid insomnia. c. monitor renal funx test. ANTITHYROID - (PTU.B4 Breakfast SULFONYLUREAS (Orinase) a. Effective: Decrease in T3 and T4 (in lab data). bradycardia. . JUICE for DM type 2.give on EMPTY STOMACH (1 hr b4 or 2hrs after meals). Effective: dec phosphate (-) pain . Check HR. b. Give round the clock. teachings: s/s of hypoglycemia. Report lethargy. REPORT HE FOLLOWING: insomnia. palpitations Take meds LIFETIME (same w/ meds 4 neuro). assess for constipation . monitor the blood sugar level in early AM and supper time  INJECT AIR FIRST to NPH then inject air and WITHDRAW FIRST with REGULAR. effective – N bld sugar level. PR and kidney funx test. Health Teachings: a. fever. give in AM b4 meals. Causes hypokalemia – therefore check Increase fld intake – to avoid DIURETICS Target Organs a.bulk forming .dizziness/drowsiness Hypersensitivity agranulocytosis (check CBC) . COLCHICINE TEACHINGS: - .ONSET: 8-12 wks ONSET: 1-3 wks - LOOP DIURETICS (lasix) effetctive: incrase urine output. PR and BP K-SPARRING (triamterene.s/effects: NAV + .48 a.has anti-inflammatory effect by . c. b. d. give AT HS (if NOT diagnostic procedure). s/e: diarrhea. monitor for hypokalemia. Tubules give in AM. electrolytes e. Diamox – exerts effect at Proximal Convuluted Tubules. give in morning to prevent nocturia. Lasix – at Loop of Henle.15-30 mins effective : (+) BM. give in AM. orange THIAZIDE (diuril) - LAXATIVES (dulcolax) Colace Metamucil Dulcolax Lactulose dependency a. dehydration – stool softener . give K rich food – banana.promotes excretion of uric acid . c. teachings: monitor for hypokalemia level and I & O. give AFTER MEALS –for dyspepsia. urine output.acid of u. meds is given in short duration only because of teachings: be near or stay near CR. NO lactulose for pt w/ diarrhea.prevents or dec formation preventing deposition of u. b. acid @ joints . K level.URICOSURIC .for CHRONIC GOUT . Diuril – at Distant Con.rapid acting . teachings: monitor for HYPERKALEMIA check PR and K ANTIGOUT PROBENECID ALLOPURINOL . check I & O. aldactone) - effective: inc. b. report muscle weakness.for ACUTE GOUT .NAV + Bldg and Bruising . c. therefore check if pt is check if pt has skin irritation – may burn the TOCOLYTICS (Yutopar. it causes blurring of vision and brow pain. check urine output. teachings: signs of Ca Intoxication: hypotension. monitor I & O and IOP OXYTOXIC PITOCIN To induce labor prevent post partum hemorrhage Effective: Firm and Contracted Uterus Give anytime If IV. Monitor uric acid levels. retin-a) pregnant. drug of choice for pre-term labor. skin decrease sebaceous gland size. c. give ANYTIME (but if pt for surgery.49 a. urine output (N 30ml/hr) c. check RR – at least 12/min d. relax the uterus. check patellar reflex – shld be (+) knee jerk HOLD if RR – 10/min and urine output: 15ml/hr CARBONIC ANHYDRASE INHIBITORS (diamox) Antidote: Calcium Gluconate for GALAUCOMA – lifetime. give b4). check bld pressure. report: s/s of dehydration bec of diuretic effect c. Give ANYTIME – but for LIFETIME. administer meds at lower conjunctival sac. effective to pt with MENIERE’S DSES – dec vertigo teachings: a. urine output. b. effective: (-) pre-term or relaxed uterus. effective: N IOP and Inc. b. given in AM to prevent insomnia. blurred vision d. b. piloca) DECREASE IOP (N12-21) for pt w/ glaucoma. hypothermia and hypocalcemia b. press the inner canthus for 1-2 mins to prevent systemic side effects (hyperglycemia and hypotension) MYDRIATRIC (AK-Dilate) - effective: pupillary dilatation. to decrease production of acqueous humor. avoid sunlight: photosensitivity pregnancy: fetotoxic . Teachings: a. Increase ORAL FLUID INTAKE. teachings: may cause blurring of vision lower conjuctival sac ANTI-ACNE (acutane. give: ORAL – B4 meals and IV – anytime. MgSO4) a. MIOTICS (timoptic. use “piggy back” METHERGIN To . Uterine Contraction – especially the duration – N 30-90 sec . Check Force. E2gel)  effacement -  Pt w/ COMPLETE HEART BLOCK: give ATSO4 – it increases HR anti ulcer drug to dec gastric acidity. assess for diarrhea and gastric irritation. Duration and Frequency of Uterine Contraction TIPS ON PHARMACOLOGY  Patient receiving DIAZEPAM. decrease ripening of the cervix w/c leads to then dilatation then abortion.report if beyond 90 sec – sign of uterine hypertonicity e. give after meals. REPORT the ff: HYPOTENSION (due to inactivation of ANS – neurological effect of drug). What shld the nurse do? – VERIFY THE PT DIET  COGNEX – given with AZEIMERS’S DSES – to increase mental functioning PROSTAGLANDIN (cytotec. check for pregnancy bec it may cause abortion Pt w/ PVC : bedside : XYLOCAINE  Pt w/ DIVERTICULITIS (pt has diarrhea) – the ff meds were given: what meds the nurse shld question : LACTULOSE  Morphine S04 given to pt with Pul. the nurse notice that there is no change in patient behavior. Hypertension (cardiovascular effect of the drug) d. obesity and Inc appetite  Pt is taking LEVODOPA – observe for URINARY RETENTION  ADREAMYCIN – causes hemorrhagic cystitis  DESMOPRESSIN ACETATE – administered INTRANASALLY . w/c meds can be given – ZOFRAN  Expected side effects of STEROIDS : wt gain. 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. Headache c.50 Teachings: a. Check BP. b. the nurse shld expect for hypoglycemia – LATE in the AFTERNOON HEPA A (enteric) yes x yes C (universal) yes yes GW M AIDS (universal) yes yes x yes GL yes x yes x yes yes x yes yes yes yes yes MENINGITIS/SEPTIC (enteric) yes x x x SCABIES (contact) yes yes yes yes TB (tb Precaution) x yes yes yes PEDICULOSIS (contact) yes yes yes yes yes TYPES OF PRECAUTION H yes x B (universal) yes MRSA (contacts) yes yes P x P – private room H – handwashing GL .51  DIARRHEA (enteric) yes x x FESO4 – shld be given w/ orange juice  ASPIRIN I s given to pt w/ TIA – to decrease platelet aggregation  Pt taking ANCEF – observe for skin rashes  Pt to receive NPH at 7:30am.gloves GW – gown M .mask AIDS – universal yes yes x . ductus venosus) c.52 Norwalk Virus – respiratory Hepa A – contact MRSA – contact Scabies – contact  The disorders result as alteration in the function of HEART (pump).E. 05) Nocturnal dyspnea – diff.S. all factors necessary for appropriate cardiovascular functioning are present at birth EXCEPT VIT.-do. Pain and Paroxysmal Nocturnal Dyspnea  For pediatric patient: observe for PALLOR – if (+) indicates ANEMIA for baby Day 6 (Feb 9. note the CARDIAC RATE of pediatric pt (minimum $ y.normal – “lubb” S2 .“dub”  - Priority: Oxygenation in assessing S1 & S2 use BELL of steth . ductus arteriosus.A. – 70) REPORTABLE S/S FOR ADULT  Palpitation. BLOOD (transport mechanism of oxygen. b. of breathing at night Paroxysmal ND – when pt feels as if he’s D. nutrients. there are structures which are present at birth that may alter the route of blood circulation (present at birth: foramen ovale.S (MEDICAL-SURGICAL NURSING) drowning HEART SOUNDS: GENERAL CONSIDERATION S1 . older c.E. K (w/c is produced by intestinal mucosa). PEDIATRIC CONSIDERATION a.S. hormones & CO2) and BLOOD VESSELS (passageway).I. children – 90-110. c.related to fluid loss (pt w/ open wound. e. Mitral Valve Dses)  HYPOVOLEMIC . Murmur) Diaphragm – for HIGH PITCH SOUND c. Hypotension. Altered level of consciousness (dec bld circulation – result to dec o2 in the brain). MI. Age Gender Surgery Secondary to existing medical condition (ex. Atherosclerosis Heart Dses. b.53 S3 . Tachycardia and Tachypnea Patient in shock. f. Bld Trans – for jehova’s use plasma expander) SHOCK ANEMIA mp: decrease in circulating blood volume MP: Decrease RBC due to decrease production or increase destruction TYPES Risk Factors:  CARDIOGENIC – pump failure (CHF. burn)  ANAPHYLACTIC cause by allergic reaction (laB procedure w/ dye. Priority Intervention: Fld replacement (D5Lr. NSS.there is also (+) pallor and (+) oliguria – due to dec bld circulation & narrowing of bld vessels Lab Data (to check bld HEMATOCRIT (N-35-45%) volume circulation) - – check check Urine Output .BELL – for LOW PITCH SOUND (ex.N for Pediatric pt (ABNORMAL for adult pt – it indicates CHF or Aortic Stenosis) Steth . b. d. traumatic injury. Iron Deficiency Anemia (IDA) Pernicious Anemia (PA) Folic Acid Deficiency Anemia (FADA) Sickle Cell Anemia (SCA) Aplastic/ Fanconis Anemia (AA) Talasemia Anemia (TA) .check CVP Nsg Dx: FLD VOLUME DEFICIT rel to dec in Circ Vol. poison)  NEUROGENIC . asthma. Renal Failure) Kidney – produce erythropoiten that stimulates bone marrow to produce RBC TYPES: a. Septicemia) TRIAD SYMPTOMS OF SHOCK a.caused by vasomotor collapse (vasomotor – located @ medulla oblongata w/c is responsible for dilatation & constriction of bld vessels)  SEPTIC – due to systemic infection (ex. check Hgb SCHILLING’S TEST (24hr urine) . deep IM. Female: 1216) Characteristic of RBC: HYPOCHROMIC & MICROCYTIC Nsg Dx: Activity Intolerance S/S: 3F (fatigue. there is that GASTRIC ATROPHY w/c leads to dec in the Intrinsic factor Lab data: Decrease in HgB (N male: 14-18. Oral FeSO4 (take w/ orange juice) if ELIXIR – use straw to avoid staining of Lab Data: teeth if IM (inferon) – “Z” track method a. characteristic of patient: chubby but pale they are also called “milk babies” those baby 5 yo but still taking milk are poor source of iron) PERNICIOUS ANEMIA MP: Nutritional Deficiency - S/S : Fatigue Fainting Forgetfulness Pallor. provide patient with BED REST – due to fatigue common in infants and children. fainting. common in POST GATRIC SURGERY Main Problem: Lack of INTRINSIC FACTOR at the stomach (intrinsic factor – the one that absorb vit b12) In elderly.54 (for Z track IM – PULL SKIN LATERALLY. “egg yolk” – iron. b. dried foods. . forgetfulness) Beefy Red Tongue or glossitis Peripheral Neuropathy (tingling sensation at lower extremities – usually both legs are affected) Priority Intervention: a. “egg white” – CHON).IRON RDA – 15-30 mgs/ day eg. Diet: iron rich food – (organ meat. c. cold clammy skin Dyspnea (due to dec RBC) common in elderly. wait 10 seconds before pulling the needle) FeSO4 – evaluate AFTER 4 weeks to check the effect IRON DEFICIENCY ANEMIA (milk b. Correct the deficiency – by administering iron supplements. WBC & PLATELET . Once a month for lifetime). Aplastic/ Megaloblastic Crisis – bone marrow depression w/c resulted to DEC RBC.55 c. b. folic acid in the diet – g. NEUROPATHY Lab Data: HgB Folic Acid level (N 4mg/day) – green leafy veg. NEUROPATHY) PI: Inc. Spleenic Sequestration Crisis – massive entrapment of red cells in the spleen & liver c. Infections Conditions that lead to SHOCK S/S: 3Fs + Fever (due to dehydration) + Pain + Jaundice Hepatomegally Complications: a. lactating and overcooked food.bld vessels obstruction by rigid and tangled cells w/c causes tissue anoxia and possible necrosis b. Bed rest – due to fatigue    FOLIC ACID DEFICIENCY ANEMIA common in infants. Bed Rest SICKLE CELL ANEMIA - autosomal recessive hereditary 1 PARENT W/ TRAIT 0 BOTH PARENTS w/ TRAIT 25% I parent TRAIT. neuropathy presence of “S or C” shape Hgb due to dec O2 (SICKLING OF RBC) STATUS TRANS N TRAIT TRANS DSES Priority Intervention:  a. (spinach) Nsg Dx: Activity Intolerance (NO RISK FOR INJURY coz NO P. leafy. RBC characteristic : MACROCYTIC & HYPERCHROMIC Nsg Dx: Activity Intolerance Risk for Injury due to p. 1 DSES 50% BOTH parents w/ Disease 100% 50% 50% 25% 50% 0 50% 0 0 Risk Factors: Dehydration (dec in circ bld volume – result in sickling of RBC). pregnant. Vasocclusive Crisis (hallmark of the dses) . Main Problem: Deficiency in Folic Acid or VIT B9 or FOLACIN S/S: all symptoms of pernicious anemia EXCEPT P. Correct the deficiency – give Vit B12 (IM. adolescents. LEUKEMIA . Italian. Reverse Isolation. Bleeding & Clotting time Nsg Dx: Lab Data: Activity Intolerance (dec in RBC) Risk for Injury (dec in WBC and Platelet) PI: Bld transfusion. Bed rest HgB Clotting and Bleeding Time Nsg Dx: Activity Intolerance Risk for Injury PI : Bld Transfusion.56 Lab Data: Sickledex Test (+) Turbid Solution MP: Hereditary Autosomal Dominant – common in female and male Nsg Dx: PI: Activity Intolerance Fld Volume Deficit Pain – due to vasocclusive crisis There is a defect in polypeptide Chain of HgB – ALPA and ETA Chain – there is RBC destruction Hydration and relief of pain (inc oral fld intake) Prevent dehydration Meds for Pain – Morphine SO4. Genetic Counseling. Major TA – severe anemia + Spleenomegally Lab Data: HgB. acetaminophen Since HEREDITARY – refer to geniticist APLASTIC ANEMIA Types: MP: Hereditary (there is DECREASE IN RBC. Minor Thalasemia Anemia – mild anemia: 3Fs b. Greeks. WBC & PLATELET) Autosomal Recessive a. IVF Dietary supplements of Folic Acid and Iron Surgery (last resort) THALASEMIA Risk Factors: Common Chinese. Indians in Blacks. CBC. Clotting Factors Platelet. Intermedia TA – more severe anemia + Speenomegally Jaundice (inc deposition of iron @ tissue) Hemosidorosis S/S: 3Fs + Pallor + Dyspnea Risk for Infection (dec in RBC) Bleeding (dec in Platelet) c. LYMPHOCYTIC – common in young children (proliferation of lymphocytes) b. cause: idiopathic S/S: Hemarthrosis – bldg between joints that usually affects ankle.Autosomal Dominant – Mother and Father IDIOPATHIC THROMBOCYTOPENIC PURPURA (ITP) or WERLHOF’S DSES - common in BLACKS.000) TRAID S/S:    petechiae ecchymosis hemorrhage (all signs of bleeding) 20. Hemo.000 – 450. Deficit (due to bldg) Anemia (initial) + 3Fs Bleeding Infection PI : Lab Data: SAFETY –prevent bleeding Give pt platelet.000K) – expected NDx: PI: Risk for Injury Activity Intolerance Risk for infection Bed rest Avoid Contact Sports Reverse Isolation Blood transfusion Bone marrow transplant HEMOPHILIA - inherited – bldg disorder TYPES: a. IVF and Bld Transfusion Corticosteroids – “wonder drugs” WBC – hyperleukocytosis (150 – 500.deficiency in Factor 9 Von Willebrand’s Dses – common in male and female HEMPPHILIA A and B mother to male) Autosomal Recessive Link (from Von W Dses . B . A . c.deficiency in factor 8 Hemo.57 MP: proliferation of immature WBC unknown (viral and autoimmune) Characterized by Remission and Exacerbation s/s: Types: a. MYELOGENOUS – adolescent and adult (proliferation of granulocytes) lab data: Platelet Count of less than (spontaneous bldg) (N 150. Hematoma Hematuria .000 Nsg Dx: Risk for Injury Fld Vol. knee and elbow joints. b. w/c of the ff is EXPECTED MANIFESTATION – HEMARTHROSIS.  a 7 yo boy with HEMOPHILIA was admitted.INCLUDE VEGS. w/c of the ff shld the nurse instruct the pt to do .Inc. w/c one is MOST SUGGESTIVE of CARDIOGENIC SHOCK .  The nurse admitted a 4 yo child with SICKLE CELL DSES – the priority for the patient is – HYDRATION. HRate from 84 to 122 bpm.“MY CHILD DRINKS 2 QUARTS OF MILK/DAY”. AND MEAT in your diet at least 1 meal a day. COLD COMPRESS.  a mother of 15 mos old child with IDA makes the ff comment.58 Hematemesis (above mentioned are signs of HEMORRHAGE) Lab Data : PROLONGED CLOTTING TIME Nsg Dx : Risk for Injury PI : SAFETY then RICE (REST. w/c one is related to child condition .  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 TYPICAL for patient w/ ANEMIA SHORTNESS OF BREATH ON EXERTION. ELEVATE) For JEHOVAH’S (cryoprecipitate) instead – use plasma  pt w/ IDA has NSG DX of ALTERED NUTRITION LESS THAN BODY REQUIREMENTS.  common manifestation of LYMPHOCYTIC LEUKEMIA is – PETECHIAE. IMMOBILIZE. CARDIOVASCULAR PEDIATRICS FETAL CIRCULATION .  w/c of the ff is indicative of thrombocytopenia HEMATURIA expander TIPS FOR BLOOD DISORDERS  If all of the ff data were obtained by the nurse. ARTERY AORTA Therefore. closes at birth) AORTA R Ventricle LA LV LUNGS L VENTRICLE DUCTUS ARTERIOSUS (functionally closes by 3-4 days at birth) L ATRIUM P. . if these 3 fetal CONGENITAL HEART DISEASE structures will not close. closes at birth) Vena Cava UMBILICAL ARTERIES Right Atrium FORAMEN OVALE (functionally.59 3 FETAL STRUCTRUES PLACENTA DUCTUS VENUSUS UMBILICAL VEIN LIVER (functionally. Medical Conditions – DM . pox .60 CONGENITAL HEART DISEASE ACYANOTIC HEART DSES CYANOTIC HEART DISEASE Signs and Symptoms:  Difficulty feeding  Retarded Growth  Tachypnea/Tachycardia  Frequent URTI  ANS – brow seating Complication: CH Failure (check for “murmur”) CVA (due to plycythemia – Inc RBC) Lab Data: 2 D Echo Nsg Dx: Altered Tissue Perfusion Dec Pulmonary Bld flow Decrease Pulmonary Obstructive CHD PI : Oxygenation Surgery If < 2yrs old prepare the patient the moment the diagnosis was confirmed/ determined. Vent.Maternal Infection – measles. therefore prepare the child 3 days prior to surgery) If > 7yo – parents decision .Age 40 and above . c.Alcoholism For 2-7 yrs old – surgery is equal to child age ( ex 3yo. Septal Defect (most common) Pulmonary Stenosis Tetralogy of Fallot (most common) Atrial Septal Defect Aortic Stenosis Transposition of the Great Vein Patent Ductus Arteriosus Coarctation of the Aorta Truncus Arteriosus Tricuspid Atresia Usually due to: . Hypertrophy. right vent. : SQUATTING Surgery PATENT DUCTUS ARTERIOSUS COARCTATION OF AORTA connection problem : P Artery and Aorta “machinery-like murmur” (+) brow seating (+) retarded growth (+) tachycardia/ tachypnea Higher BP in the Upper Extremities and Lower BP in the Lower Ext. vent septal defect “boot-shape heart” Lab Data : BP.61 - tet spell – squatting w/ cyanosis LAB DATA : 2 D-echo Complication : CVA – check for RBC Count Nsg Dx : Risk for Injury PI : Oxygenation Position the Pt. 2 D-Echo PI : Oxygenation Position the patient: Orthopneic or semi – fowler’s position . coarctation of aorta. 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. of SCAR FORMATION that can lead to MI). w/c intervention is priority – decreasing the metabolic demand of the heart S/S : High Spiking Fever for 5 Days Lymphadenopathy Strawberry Tongue Palmar and Feet Desquamation Lab Data : No Specific Diagnostic test Check ECG Nsg Dx : Altered Tissue Perfusion Altered Thermoregulation Altered Skin Integrity Diet : High CHON TIPS FOR CARDIOVASCULAR – PEDIA  w/ of the ff is an OUTSTANDING SYMPTOM OF CARDIOVASCULAR PROBLEM in children – difficulty in feeding. Risk Factors: Family History Atherosclerosis Smoking Elevated Cholesterol HPN .  a child who was brought in to a well baby clinic turns cyanotic while crying – REFER to the physician. especially to JAPANESE children and toddler 5yo and below  w/c of the ff data in mother health history indicates a risk factor for congenital heart disease – ADVANCE AGE.if LESS THAN 1 yo – flex lower extremities towards the abodomen.  w/c of the ff is an appropriate intervention for a child who keeps on squatting because of Tetralogy of Fallot . 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.  the BLD VESSELS INVOLVE in PATENT DUCTUS ARTERIOSUS – pulmonary artery and aorta.62 KAWASAKI’S DISEASE due to acute vasculitis (inflammation of bld vessels) of the heart.  when admitting a pt w/ suspected congenital heart disease. 63 Obesity Physical Inactivity Stress CAD HYPOXIA ISCHEMIA NECROSIS ANGINA PAIN Myocardial Infarction – “ jaw pain” MTOCARDIAL INFACRTION ANGINA  this leads to decrease O2 – and will result to the conversion of aerobic metabolism to anerobic thereby resulting to the production of LACTIC ACID – that will stimulate the nerve ending of the heart w/ will produce/ result to PAIN that is precipitated by: EATING Elimination – due to valsalva manuever Exercise/effort/ exertion Emotion Extreme Temperature – “cool temp” – vasoconstriction sEx Precipitated by 6E’s Pain confined at sternal area  Pain that resembles “indigestion”. . excruxiating Pain that resembles “pressure”  Pain radiates to the L Jaw. L arm. L shoulder  Relieved by SO4 Opiods (MORPHINE) Relieved by rest & NITROGLYCERIN  Pain occurs AFTER MEAL (post cebum) or AFTER ACTIVITY SAME  S/S of above mentioned + SHOCK s/s – esp to CARDIOGENIC SHOCK w/c is due to PUMP Failure – that leads to dec cardiac Output that leads further to CHF. crushing. 5 mins interval Decubitus Angina – when pt is lying down Intractable Angina – unresponsive to tx Post MI Angina  For patient with MI – focus on complications : a.position : SEMI-FOWLER’S . PVC or PVBeats – defibrillation/ cardioversion b.  Goal of CARE Variant/ Prinzmetal – severe form of Angina. a.64  ECG – initial change is ST SEGMENT DEPRESSION w/ SAME T WAVE INVERSION b.administer meds: Nocturnal Angina – occurs at night. Ventricullar Fibrillation – Lidocaine – s/e “rashes” effective: tingling sensation. Diet : Low Na and Low Cholesterol Increase CHOLESTEROL SAME HDL – “good” or Healthy – liver for metabolism – 30-80 LDL . MI : Morphine SO4 – monitor RR. ANTIDOTE : Naloxone HCL – Narcan ANGINA : Nitroglycerine – dark container give b4 activity maximum of 3 doses.“bad” – peripheral vascular system – bld vessels60-80 CARDIAC ENZYMES #1 Myoglobin SAME Troponin CK – within 2-3 days LDH 1&2 – within 10-14 days HEALTH TEACHINGS:   Nsg Dx : PAIN Altered Tissue Perfusion Impaired Gas Exchange Identify types of Angina: Stable Angina – predictable – angina that occurs w/ activity.  Priority : Airway (Oxygenation) Unpredictable – relieved by Nitroglycerin. To decrease oxygen metabolic demand .administer O2 as ordered . effective : (-) pain. sublingual provide rest – due to pain CARDIOVERSION DEFIBRILLATION . .  Forward Effects : decrease cardiac output – dec in tissue O2 perfusion – that leads to overwork respiratory system LEFT HEART FAILURE – early signs of CHF Therefore.Coronary Dses & HPN .esp.position during sex : passive – let the girl do her share   ACTIVITY – advised pt to have frequent rest period. Right Heart Failure – will be the late signs of CHF as complication of LHF Risk Factors to Heart Failure: . yellow cake  FOR ANGINA APIN – instruct patient to report pain that last more than 2o minutes (indicative of MI). PUMP FAILURE EFFECTS:  Backward Effects : backflow of blood – systemic congestion.Renal Failure LEFT SIDED HF – dyspnea and other “pulmonary s/s” – “crackles” RIGHT SIDED HF – systemic effect – distended jugular vein Ankle edema Ascites Hepatomegally . DIET : avoid PROCESSED FOODS. for VTACH w/ PULSE PULSE .for VTACH w/o  SEX – for pt w/ MI – resume if pt tolerate 2-3 plights of stair w/o pain.  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.65 .synchronize unsynchronized . MILK Salty Sea Foods Pastries – esp.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.take meds b4 sex.Arrythmias . . b. ECLAMPSIA + Bleeding = HELP SYNDROME TYPES: a. ESSENTIAL HPN – cause – unknown BENIGN – usually of long duration. HYPERTENSIVE DISORDER OF PREGNANCY  Obesity .INC. a. onset is CHRONIC MALIGNANT – acute or abrupt onset. Activity – rest b. d. DIET : LOW Na – NO PMS HEALTH TEACHINGS : a. PREGNANCY pre hypertensive phase 120/80. Toxicity: yellow vision.age of viability) wks of gestation Altered Tissue Perfusion Ineffective Breathing Pattern – for LHF Fld Volume Excess – for RHF PRIORITY : Oxygenation Position: Semi-Fowler’s Administer: Digoxin – absorb in GI Vasodilators Diuretics Morphine – for CHF – it causes pheriperal vasodilation by Decreasing the amount blood going back to the heart. report s/s of complications  DIGITALIS – D. dietary counseling – NO PMS c. c. PRE-ECLAMPSIA S/S + convulsion. therefore N BP : 110/70 if BP elevated B4 20-24 wks & cont after delivery – CHRONIC HPN Risk Factors: Levels of PIH  Common in BLACKS. short in duration SECONDARY – related to existing medical condition . BP + EDEMA & Proteinuria (s/s of PRE-ECLAMPSIA)  Stress  Smoking b.66 LEFTS SIDED HF HF RIGHT SIDED Lab Data : Swan Ganz 12. Abdl pain & Headache . V Cava – 5-12) PAP (N 20-30) PCWP (N 8-13) CVP (N R – 0- X-ray Nsg Dx : HYPERTENSION INDUCED HPN X-ray MP : blood pressure higher than Elevation of BP that occurs after 20-24 140/90 (hypertensive state) (5 mos.ECLAMPSIA PHASE c.  Muscle weakness (hypokalemia) – that can lead to arrythmia  Dyspnea – s/s of pulmonary edema. PROTENURIA is <5mg/hr (N BP 160/90. PROTENURIA is >5mg/hr PIORITY: HEADACHE and ABDOMINAL PAIN – s/s of ECLAMPSIA.simvastatin & lovastatin – give after meal nighttime  Monitor liver Funx test – meds above are hepatotoxic Pts w/ PIH meds: a. Stabilize BP How? I. indicative of impending convulsion. MILD .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.67 HPN IN PREGNANCY – usually related to generalized spasm of the arteries PRE-ECLAMPSIA TYPES: a. Inc BP and Inc Cholesterol Nsg Dx: Altered Health Maintenance Risk for Injury     Stress Management Deep breathing Diet : Low Na/ Cholesterol Position : if inc BP – supine position II.. PHARMACOLOGIC MEASURES  Antihypertensive  Diuretics  Aspirin  Antilipimic .5-1GM) b. MgSo4 – antidote is CAgluconate b. SEVERE BP 140/90. Non-Pharmacologic Features ECLAMPSIA + BLEEDING = HELP SYNDROME H – emolysis E – levated Liver Enzyme L – ow P. Darkened room – to dec stimulus thereby preventing convulsion . of Spasm of Arteries Hardening of arteries due to fatty deposits Arteries & veins of lower ext of Upper & lower ACUTE CHRONIC INTERMITTENT .68 PERIPHERAL VASCULAR DISEASE Arterial Obstruction Venous Obstruction Color pallor Edema (-) or mild Nails brittle nails Pain intermittent claudication (pain @ gastrocnemeus area) Pulse (-) Temperature cold Ulcer dry & necrotic ruddy (+) & severe N homan’s sign (+) warm wet TYPES: BURGER’S DSES RAYNAUDS ARTERIOSCLEROSIS OBLITERANS (THROMBO ANGITIS OBLITERANS) common : MALE MALE AREA Lower Ext.lower ext Affects arteries Arteries ONLY and veins MP : Upper & Arteries ONLY “Angitis” – inflam. Lower Ext AFFECTED : FEMALE Upper Ext – 97% 3% .(+) pain usually related to . CLOT + Inflammation Clot job related (prolong sitting/standing) pregnancy hereditary secondary to existing medical condition s/s : dilated tortous vein dragging sensation “heaviness” edema (unilateral/ bilateral) – tape measure to monitor leg circumference Pain Lab data: 1.(+) pain that narrowing of blood vessels. Nsg Dx : DOPPLER USG PAIN Altered Tissue Perfusion Hx Teachings :  Elevate the legs above the heart. . conservative test – TRENDELENBURG TEST – pt lie down. accompanied by color changes: PALLOR that progresses to CYANOSIS then REDNESS & aggravated by exposure to cold – NO SHOVELING OF SNOW & COLD BATH & exposure to cold – wear gloves S/S: Outstanding s/s is INTERMITTENT CLAUDICATION – pain that worsens w/ activity or pain that is relieved by rest.69 . .aggravated by smoking – causes further narrowing of bld vessels LAB DATA : Inc WBC & ESR Inc Cholesterol and Ca DOPPLER USG Nsg Dx: Altered Tissue Perfusion same Pain -doPI : Relief of Pain -do- same -do-do- MEDS : (for all types)    Anticoagulants Vasodilators (papaverin – pavabid) Antihypertensive DIET : Low Cholesterol VARICOSE VEIN PHLEBOTHROMBOSIS THROBOPHLEBITIS weakening of venous valves. 2. elevate/ raise the legs then stand up and observe for bulging of vein.  shake the pt – are you ok? If breathless & pulseless then. w/c of the ff is expected – calf pain after short walking (intermittent claudication). disorientation.  A pt was diagnosed w/ MI develop atrial fibrillation – this may possibly lead to – CEREBRAL EMBOLISM. . .  A pt w/ CHF was admitted exhibiting confusion.could be related to aging and HPN TYPES: Prepare pt for Surgery CARDIO-PULMONARY RESUSCITATION (CPR) indicated for cardiac arrest when pt is BREATHLESS and PULSELESS. 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.  ACTIVATE the EMS – Help!  CPR (1 or 2 rescuer : 15 : 2)  In 1 minute. visual disorders & hallucination – the nurse best action is to – CALL THE PHYSICIAN.weakening of portion of abdl aorta – leading to dilation. #2 skin color S/S: Pulsating Abdl Mass Low Back Pain Higher BP in Upper Extremities If RUPTURE occurs – could lead to SHOCK LAB DATA : PRIORITY : Altered Tissue Perfusion Risk for Injury NO ABDOMINAL PALPATION bec it may lead to rupture – PLACE WARNING AT THE DOOR OF THE PT. there will be 80 compression and 15 – 20 rescue breaths Depth of Compression : 11/2” – 2” Fusiform . COLD COMPRESS ABDOMINAL AORTIC ANEURYSM (AAA) .70   Use support stockings.part of inner intima and media was dissected w/c lead to the pushing of tunica adventitia to bulge Saccular If too deep .it may fx the liver Effect of CPR : #1 (+) Pulse. TIPS FOR CARDIOVASCULAR – ADULT  A nurse is assigned to a pt with arterial dses of lower extremities.entire wall is affected Dissecting . note for abnormalities in RATE.  A pt with R sided HF will manifest – distended jugular vein  use steth directly on pt. when shall I resume sexual activity? – when you can climb 2 plights of stairs w/o shortness of breath then sexual activity is safe. . .  BIOTS – increase in depth followed by apnea.  when the pt chest is hairy.nero case  Kussmauls – deep rapid breathing.relaxation and stress mgt.  Apneustic – forceful inspiration followed by slow expiration – dying patient .  Tachycardia  Tachypnea  Dyspnea  Cyanosis – late sign of respiratory Distress Key Points for Assessment .  A pt has R sided CHF.#1 or Early sign for respiratory distress. 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.  Pt exhibits intermittent claudication – another sign of peripheral dses is w/c of the ff – tropic skin changes. may indicate Pneumonia) and rapid breathing Reportable Signs and Symptoms : common TO ALL RESPIRATORY DISORDERS “RE TACHY TACHY D C”  RETRACTIONS .  Ff MI. w/c of the ff is expected – hepatomegally.  In addition to assessing a pt w/ Burger’s Dses.  In utilizing mind over body principle for pt w/ HPN – w/c intervention is appropriate .pt w/ neuro impairement  Cheyne-Stroke – increase in rate and depth of breathing followed by apnea.  Apt w/ CHF who is taking diuretics exhibits the ff. w/c of the ff data supports the Dx.71  A nurse is assessing a pt w/ MI – w/c of the ff is the characteristic of PAIN – pain radiates to the jaw. w/c requires further investigation (not expected to pt) – wt gain of 3 lbs in 2 days.  Note for chest indrawing (if +. – smoking. RHYTHM & DEPTH Common CHARACTERISTIC in Breathing RESPIRATORY General Consideration:  use the DIAPHRAGM of the steth when assessing breath sounds. skin – because clothing my interfere w/ auscultation. TACHYCARDIA Factors: and Cyanosis Risk S/S : WHEEZING sound – due to obstruction Orthopnea Whitish Sputum Lab Data : Pulmonary Funx test Incentive Spirometer . Dx Procedures: Pre-Term. who died w/ SIDS (usually 2-3 sis/ bro – died) d. HYPOVENTILATION Cause: Lack of O2 a. 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. Those w/ episodes Siblings of those Hypoventilation Cardioneumogram – measures O2 Polysonography ABG Analysis Effect: ACIDOSIS Tx :  Administer Theophylline (N 10-20 mg/ml) S/Effects: NAV and Insomia  Caffeine  Assist mother threu grieving process HYPERVENTILATION ALKALOSIS Cause : lack of CO2 – the pt will decrease rate of breathing to save CO2. can lead to acidosis – and the brain will compensate by hyperventilating – and increase elimination of CO2 will cause ALKALOSIS. Hx Teaching : Teach parents CPR (esp to Apnea of Infancy) ASTHMA MP : Inflammation of bronchioles that leads to excessive mucus production that resulted to narrowing and obstruction. of Apparent Life Threatening Events c. b. Risk Factors : Environmental factors Emotion Effort/ Exercise APNEA OF INFANCY SIDS/ CRIB DEATH Occurs in Full Term Baby (37wks onwards) occurs in Pre-term Usually s/s : episodes of APNEA. Distress Syndrome – a group of symptoms (mgt: maintain temperature).72 At birth. co2 then combine with H2O to form carbonic acid – if inc.  AVOID PROPANOLOL and ASPIRIN – causes BRONCHOSPASM. viocase) . pancrease.73 Nsg Dx : Ineffective airway Clearance PI : AIRWAY Intervention : Bronchodilators – theophylline Rest Oxygen – low flow (1-2 l/min) – higher than this will result to decrease in the stimulus for breathing – w/c is CO2 Nebulization Chest Physiotherapy – b4 meals or at bed time High Fowlers Intermittent Positive Pressure Breathing Aerosol Liberal Fluid Intake Meds : Aminophylline Steroids Theophylline Histamine Antagonist Mucolytic Antibiotics multi system dses (GI and Respiratory System) characterized by excessive mucus production by exocrine glands.  Exercise – “blowing exercises” – bubbles. GI Therapy – Administer Pancreatic Enzyme (pancreatin. ABDL DISTENTION Malabsorption Syndrome – STEATORRHEA – foulsmelling stool w/ Inc Fats & Bulky Salty to Kiss – bec skin becomes impermeable to Na Common Complications: because of thick mucus plug MALE – Aspermia – low sperm count Sterility FEMALE – Difficulty in conceiving Nsg Dx : Hx Teachings :  Appropriate rest. Respiratory GI Hereditary Autosomal Recessive For each pregnancy - TRAIT TRANSMISSION – 50% Chance for DISEASE TRANSMISSION – 25% S/S : MECONIUM ILEUS – within the 1st 24-36 hrs – if baby fail to defecate – suspect for CF.  Activity – avoid those that will expose pt to allergens. Increase Fluid Intake. trumpet CYSTIC FIBROSIS Knowledge Deficit Altered Elimination Altered Sexual Functioning Lab Data : Sweat Chloride Test – N (if sweat) 10 – 35 mg/dl – INCREASE IF (+) CF (if serum) 90 – 110 mg/dl -doPI : since two system are affected: Respiratory Therapy – blowing of trumpet. Of BRONCHIOLES “barking-metallic cough” “harsh-brassy cough” “paroxysmal-hacking cough”  change clothing frequently coz mist will dampen child clothings. .74 GIVEN WITH EACH MEALS Effective : if (-) fat at stool (-) FEVER (+) FEVER-low grade (+) FEVER-moderate (+) STRIDOR WHEEZING (+) STRIDOR (+) Hx Teaching : Refer parents to GENETICIST STRIDOR – is present when the affected part is LARYNX. Humidity – place infant in MIST TENT or CROUPETTE Nsg care: CROUP DISORDER ACUTE LARYNGITIS LTB RSV/ BRONCHIOLITIS (Laryngotracheal Bronchitis) (Respiratory Synctial Virus) common in TODDLER INFANTS & TODDLER INFANTS usually (less than 6 mos) VIRAL VIRAL or BACTERIAL VIRAL Inflammation of LARYNX Inflam.  TOYS while inside the tent: PLASTIC TOYS  “no battery operated & no friction wheel toys”  at HOME: we can use NIGHT or MOIST air outside and hot shower mist at the comfort room – for child to inhale Antibiotics – Antiviral – Ribavirin Hx Teachings : SYRUP OF IPECAC – for Croup – it induces vomitingbec it will stop the spam thereby preventing further coughing.#1) – to facilitate airway. of LARYNX & TRACHEA Inflam. Lab data: P Exam ABG’s Nsg Dx : -do- ELIZA -do- INEFFECTIVE AIRWAY CLEARANCE PI : Airway – Endotracheal Tube (Tracheostomy Set . Meds: Bronchodilator – Atrovent Exercise: Blowing.75 Over distention of Alveoli Bronchus Inflammation of Gelatinous sputum + “RE TACHY TACHY D C” Risk Factors: (+) (+) (+) (+) (+) Allergy Environmental factors Pollen Elevated Immunoglobulin E (IgE) Smoking (esp to passive smokers) S/S: RE TACHY TACHY D C + “barrel-shape test” – there is an INCREASE in ANTERIOR and POSTERIOR DIAMETER of the chest Lab Data : ABG’s – to check for respiratory acidosis CXrays Nsg Dx : #1 Ineffective Airway Clearance – due to narrowing & obstruction #2 Ineffective Breathing Pattern PI :     Chronic Obstructive Pulmonary Disease (COPD) MP : group of disorders of respiratory system that lead to obstruction or narrowing of airways. the POSITION OF CHOICE : ORTHOPNEIC PNEUMOTHORAX EMPHYSEMA BRONCHITIS ASTHMA MP : partial or total collapse of lungs due to: . AIRWAY 1-2 L/min. Rest periods in between activities During ACUTE attack. management same w/ pna VIRAL PNA BACTERIAL PNA Fever : moderate-high (+) low-moderate (+) fever Cough : (+) Non productive – “thin-watery” Productive – “rusty” (+) WBC : Elevated No change or slight Lab Data : Xray and ABG’s Nsg Dx : Impaired Gas Exchange – due to exudation and consolidation of Alveoli PI :       TB Airway – O2 Position : Semi-fowler’s or Orthopneic Bed Rest Inc Oral fluid intake Antibiotics TCDB (turning. (+) Dyspnea. & deep breathing) HISTOPLASMOSIS MYCOBACTERIUM AVIUM COMPLEX Bacterial CAPSULATUM) thru Fungal (from HISTOPLASMA Bacterial from BIRD MANURE – soil & transmitted . alcoholic & Immunosuppressed pt . sounds to area auscultated. (+) Restlessness Nsg Dx : Impaired Gas Exchange Ineffective Breathing Pattern PI : Chest Tube Drainage System – restores the (-) pressure within the thoracic cavity Anterior chest tube – drains the AIR Posterior chest tube – drains FLUIDS PNEUMONIA (PNA) MP : there is INFLAMMATION of ALVEOLAR SPACES that leads to exudation and consolidation of the lungs.due to rupture of distention of alveoli Tension Pneumothorax – due to INCREASE IN S/S : Diminished Breath Sounds – (-) b. coughing. LEGIONARES DSES – acute bronchopneumonia in elderly.76 Types :   BLEB – over  TENSION Open Pneumothorax – TRAUMA Spontaneous Pneumothorax . 77 inhalation Droplets & Airborne Droplets & Airborne Droplets & Airborne Risk Factors: Rifampicin INH Streptomycin Ethambutol take above meds for 6-12 moths to avoid resistance ASIAN IMMIGRANT IMMUNOSUPPRESSION MALNUTRITION S/S : ACTIVITY same: a to e + FOREST RELATED same with TB Ask client if came from AVIARY a.  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 .  w/c of the ff intervention being carried out by LPN would require immediate intervention – suctioning the pt for 20 seconds.  Nsg Dx : Infection.low grade fever. b. body malaise or weakness. supports a dx of cystic fibrosis – MECOMIUM ILEUS in the neonate.@ least 2 (-) to be effective TIPS FOR RESPIRATORY  you observed a nurse caring for a child in a CROUPETTE. c. d.  a pt is diagnosed w/ emphysema – w/ of the ff s/s would the nurse expect to have – barrel shape chest. what would be your #1 PRIORITY? – changing the linens & clothings to keep child always dry. initially asymptomatic. if you are the nurse in-charge. coughing w/ bld streaked sputum. e.  which data in the past medical history of the pt.  the primary goal of care for pt w/ bronchiolitis is to – minimize oxygen expenditure. weight loss Lab Data : Histoplasmosis Histoplasmine Skin Test – for Mantoux Test Xray – confirmatory test Sputum . Ineffective Breathing Pattern  PROPHYLACTIVE TREATMENT OF TB – INH for TWO WKS (take Vit B6 to avoid NEUROPATHY) MEDS : Antibiotics Antiviral Meds a client w/ TB will experience . low grade fever that occurs in the afternoon. Incorporate food preferences 2 servings of popcorn – HOW MANY RICE TO GIVE UP =1 if sandwich = 1 rice Diarrhea Anorexis Lethargy Anemia Skin Rashes and seizure Musty odor of urine (due to phenyl pyruvic acid) Since (-) melanine: hair : blonde . temperature  S/S of Shock Keypoints : Specimen characteristic is usually affected by STREE. Direct methods – specimen : blood and urine Explain the methods of gathering the specimen There is Absence of Phenylalamine Hydroxylase (the one that converts Phenylalamine to Thyroxine ( a precursor to Melanin).78 c. self insulin administration – allowed to child 9 yo and above Reportable S/S :  skin changes – “have you noticed any change in your skin color” (“bronze skin pigmentation – addison’s dses)  Inc. b. 2005) PKU AUTOSOMAL transmission (inherited) RECESSIVE PATTERN of MP : ENDOCRINE General Consideration Explain to the pt the MOST COMMON METHOD of assessment: a. Involve the parents of the child. S/S : Initially – asymptomatic For OLDER CHILDREN : Consideration for PEDIATRIC PATIENT a. DIET and Normal Body Rhythm DAY 7 (Feb 10. b. Therefore (-) PH leads to accumulation of phenylalanine at the brain that leads to Mental Retardation. .prepare special education to parents  Refer to geneticist Untreated PKU can result in failure to thrive.intolerance to cold mental retardation . newborns are supplied with maternal thyroid hormones that last up to 3 mos. initially asymptomatic s/s begins 2 – 3 months behavioral s/s physical s/s – large tongue & protrudes . vomiting and eczema – and by about 6 mos. CRETENISM or CONGENITAL HYPOTHYROIDISM disorders related to absent or non-functioning thyroid. signs of brain involvement appear..prepare special education to parents  Provide list of foods allowed. Cause : Autoimmune or genetics MP : Decrease in T3 and T4  Secondary screening : done when the infant is about 6wks old – test fresh urine w/ PHENISTIX – WHICH CHANGE COLOR S/S : Dysphagia Enlarge thyroid All s/s of hypothyroidism (decrease metabolism)  Phenylalanine level greater diagnostic of PKU (4mg/dl – indicative) Nsg Dx : Knowledge Deficit Activity Intolerance than 8mg/dl – PI : no tx because it regresses (only temporary) spontaneously Nsg Dx : Knowledge Deficit Altered Thought Process Risk For Injury PI : Dietary Modification : LOW CHON and Low Phenylalanine Diet until adolescent or til 10 yo – bec b4 this time the brain mature MEDS : Lofenalac – 20-30mg/kg/day Hx Teachings :  Inform parents of the foods to be avoided.79 Eyes: blue Fair Skin LYMPHOCYTIC THYROIDITIS or JUVENILE HYPOTHYROIDISM Lab Data :  GUTHRIE CAPILLARY BLD TEST – initial screening – done after the infant has ingested CHON for a minimum of of 24 hrs.apathy – “well behave” from mouth retarded growth . Pineal Gland Pituitary Gland Thyroid Gland Parathyroid Gland Thymus Gland Pancreas 7. Parrys) PARATHYROID Pancreas ADRENALS Cushings Hypo (Graves. 8. tachycardia. Adrenals Gonads (testes & ovaries) Glands UNDER OVER PITUITARY Diabetes Insipidus SIADH THYROID Hypothroidism Hyperthyroidism (Myxedema) Basedows.  Without treatment. and nervousness – REPORT ASAP) PI : correct the deficiency Hx Teachings :  Warm environment (bec there is Hypothermia w/ cool extremities). 6. 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.  Low calorie diet : since there is decrease metabolism.  Special education ENDOCRINE GLANDS 8 glands (ductless). 5. 3. 4. 2. Hyper DM Addison’s Dses Conns .80  Prevention: neonatal screening blood test. mental retardation and developmental delay will occur after age 3 mos. retardation (adverse effect of meds : insomnia.they secrete the hormone directly to bld stream 1. .OBESE.  Adolescence to Early Adult Stage Pt is Obese  Pt is THIN  Pt is KETOSIS PRONE NONKETOSIS PRONE MODY – DM III .occurs during pregnancy Types According to WHITE’S Classification PANCREAS TYPE Alpha Cells BETA CELLS ONSET DURATION A CHEMICAL DIABETES (+) Increase Bld Sugar Islets of Langerhans B After the age of 20 C 10-19 years Bet 10 – 19 yrs old D More than 20 yrs Before 10 yrs old D1 Before 10 yrs old 10 years Glucagon Insulin (responsible for Decrease in blood sugar) Responsible in the increase Blood Sugar Absence Deficiency (DM Type I) IDDM (DM Type II) NIDDM  Juvenile Onset – B4 age of 30 Maturity Onset – After age of 30.81 .Maturity Onset that occurs in young adult. b4 age of 30 D2 >20 yrs D3 Beginning Retinopathy D4 w/ calcification of arteries D5 DM w/ HPN E F Nephropathy) w/ calcification of Pelvic Arteries w/ nephropathy (Diabetes H Diabetes Cardiopathy R Diabetes Retinopathy .combines features of DM Type I & 2. .Non-Ketosis Prone GESTATIONAL DIABETES . foot powder.BEFORE LUNCH 40 degree angle if noninsulin syringe Complication of INSULIN ADMINISTRATION:  Lipodystropy  Dawn’s Phenomenon – hyperglycemia that occurs at dawn – Early AM due to over secretion growth hormone treatment: GIVE INSULIN – NPH at 10 PM to prevent hyperglycemia at early AM  SOMOGYI Phenomenon – rebound hyperglycemia (tx: administer insulin)  Antidiabetic Agent. cut toe nail straight across  .  (2x a day).DURING NIGHT Ultralente INSULIN: NEUTRAL AREA DIABETES MELLITUS Best Site is ABDOMEN bec it is a SUBQ – 90 degree angle for insulin syringe MP : Deficiency in INSULIN – either absence or deficiency of insulin that leads to alteration in the metabolism of CHO. Cause: unknown R. CHON and FATS. snugly fitting shoes.  Exercise – it will decrease insulin requirement (in pregnancy/stress – Increase insulin req) Scrupulous foot care – check up w/ podiatrist .)  Insulin – for Type 1 Hypoglycemia Most Approximately to Occur RAPID Regular Insulin .82 T w/ Transplant of the Kidney INTERMEDIATE NPH AFTERNOON/ AFTERNOON SLOW - LATE IN THE Protamine Zinc .  Transplant of Pancreatic Cells. Blood Sugar Monitoring – in AM and supper time  Ensure adequate food intake. factors : Autoimmune Genetic Stress S/S : Polydipsia Polyuria Polyphagia – the stave cells send message to the brain to eat more Wt loss Nsg Dx : Knowledge Deficit Altered Nutrition PI : Correct the deficiency.HOW?  Diet : well balance diet – CHO – 50-70% (main source of energy and sugar for DM pt. always dry in between toes (Insulin Reaction) Coma) .  Insulin Requirement (dose will be adjusted on 2 nd & 3rd Trimester).avoid going barefoot .83 .  Increase or Overdose of Insulin. Diaphoresis EFFECTS MOTHER Overeating Decrease Hyperglycemia (bld PI : Administer Simple Sugar (fructose-fruit juice) Hard Candy (not chocolate – it is complex sugar) If unconscious – D50 .cut toe nail across . Hypoglycemia sugar level above 120) Inactivity Dizziness Drowsiness Difficulty Problem Solving Decrease Level of Consciousness + Cold Clammy Skin.BLD SUGAR BELOW 50 (Diabetic DKA HHNK Risk Factors : Modification for Pregnant Pt with DM  +300Kcal. AM Dose: PM Dose: 2:1 for Regular to NPH 1:1 for R:NPH  Missed meals. Insulin  Too much Activity Stress Infection S/S : BABY Lab Data : Below 50 Blood Sugar Level Macrosomia Hyperglycemia Hypoglycemia Therefore pre-term birth RDS Complication: Uterine Atony Congenital Defects COMPLICATION 1.  GH (growth hormone). 4. NEPHROPATHY – kidney damage. - ACTH (adrenocorticotropic hormone)  LH (luteinizing hormone).84 DKA (Type 1) HHNK (Type 2) (Hyperglycemic Hyperosmolar Nonketotic Coma) S/S : 3 P’s + Signs of Dehydration – thirst & warm DIABETES INSIPIDUS (Pituitary Glands – 3 lobes) skin Hyperglycemia pronounced GI Disturbances “Kussmaul Breathing + 3P’s Thirst and warm skin More ANTERIOR MIDDLE POSTERIOR Secrete Tropic Hormones excrete) MSH (skin color) Store Only (does not Lab Data : Increase Bld Sugar  PI : #1 AIRWAY #2 Fluid Regular Insulin Nsg Dx : Risk for Injury 2.w/c leads to cataract (eye exam annually). 6.  Prolactin MICROANGIOPATHY . ATHEROSCLEROSIS – hardening of arteries.  FSH OXYTOCIN (follicle stimulating Hormone) ADH Peripheral Neuropathy or Autonomic Neuropathy there is poor nerve impulse transmission common manifestation : impotence . OPTHALMOPATHY .destruction of small blood vessels. 3. 5. Nsg Dx : PI : FLUID VOLUME DEFICIT Administer IV Fluids Meds Synthetic ADH . urine .010 – 1.one hole of nose only    Check Specific Gravity of Urine. Evaluate the effect of meds : Deficiency: lead to D.005.85 PITUITARY GLAND Lypressin - -doHow : Given ADH (anti Diuretic Hormone) – retain h20 or flds as pt exhale to the mouth then inhale thru the nose then EXHALE to the mouth then give meds. Monitor V/S : assess for hypovolemic shock .Vasopressin – IM Desmopressin – INTRANASALLY. therefore s/s same with DM EXCEPT : POLYPHAGIA   Polyuria – 21 L/day Polydypsia LAB DATA : a.pt on NPO 24hrs B4.025) – in DI its <1.decrease in specific gravity (N 1. Monitor I & O. INSIPIDUS Excess : SIADH (Syndrome of Inappropriate Anti Diuretic Hormone Secretion) Due to or related to: Pituitary Tumor Head Trauma Injuries MP : Deficiency in ADH leads to fld excretion. FLUID DEPRIVATION Test . b. 86 - DWARFISM of Growth Plate .long.“congenital” “gigantism” ex.there is Above s/s could lead to decrease LOC coarsening of facial features + LAB DATA : Decrease Na Level (<120 mEq/L) – hyponatremia enlargement of the digits (inc. seizure. MP : Fluid Retention – result to DILUTIONAL HYPONATREMIA or H2O INTOXICATION S/S : B4 Closure . Balingit FLUID VOLUME EXCESS PI : FLUID RESTRICTION Drugs – DIURETICS + ANTIHPN – if cause by TUMOR – PREPARE PT FOR SURGERY IF after surgery – POLYURIA – report ASAP – sign of DI Lab Data : INCREASE HUMAN GROWTH HORMONE Increase Blood Sugar Nsg Dx : Risk for Injury PI : Safety Meds . in Height SIADH excess ADH. ex. shoe size) Nsg Dx : ex. HPN    After the Closer of Growth Plate “acromegally” . Marlo Aquino due to DECREASE NA – this could lead to the ff: NANU’S SYNDROME (hereditary) convulsion.Parlodel – decrease secretion of growth hormone If related to tumor : surgery PITUITARY GROWTH HORMONE DEFICIENCY EXCESS . MAHAL slender extremities and Inc. M & SEX HORMONES) (there is INCREASE G & M) .formation of sugar from Responsible for Na Retention new sources and K Excretion GIGANTISM (long slender extremity)  DEFICIENCY IN GLUCO & MINERALO : ADDISON’S Dses  EXCESS of GLUCO & MINERALO : CUSHING’S Dses/ syndrome  EXCESS of MINERALOCORTICOIDS ONLY : CONN’S SYNDROME MARFAN SYNDROME KLINEFELTERS (hereditary) (chromosomal aberrations) MP : Cardio & Eye disorder (complication) XXY Pattern (an extra X chromosome) Scoliosis chromosome – FEMALE COMPONENT MP : X of HUMAN BODY Problem is NON-DEVELOPMENT of SEX ORGAN ADDISON’S the CORTEX (OUTER) MEDULLA RESPONSIBLE FOR SECRETION OF: SECRETES THE FF: CONN’S MP : Underactivity of the Adrenal Glands Overactivity of A.87 GLUCOCORTICOIDS MINERALOCORTICOIDS EPINEPHRINE NOREPINEPHRINE (ALDOSTERONE) GLUCONEOGENESIS STRESS RESPONSE – “fight or flight” . MINERALOCORTICOIDS (there is DEC G. Cortex GLUCOCORTICOID CORTISOL Common: Male and Female Age 30-60) Female (30-50) Female (bet.w/c cause K EXCRETION & ADRENOCORTICAL INSUFFICIENCY Na RETENTION ADRENAL/SUPRARENAL (INNER) CUSHING Excessive SECRETION of Excessive ALDOSTERONE . Glands INC.coticosteriods especially Secretion from A. RF : Could be related to Surgery – removal Tumors Related to Tumor Related to . K. Na and CHON to prevent Hypoglycemia & Hyponatremia Monitor V/S. Excess Fld & E imbalance ADDISON’S CUSHINGS CONN’S PI :  Correct the imbalance – IV Correct the imbalance Check BP – give antiHPN  Diet: Inc Na Dec K . Ca Cortisone – give 2/3 of dose in AM & Vit D 1/3 in afternoon  Meds are FOR LIFE Prevent accident & Falls Diet : Low Na. Weak Pulse Weight loss. Deficit Risk for Injury Fld & E imbalance Fld & E Imbalance Fld Vol. Pendulous Abdomen Hypertension Lability of Mood (mood swings) Polyuria. INC K (hyperkalemia) Buffalo Hump.limit fld intake  Administer Steroids (Fludocortisone) DIET : Low in Calories & Na Limit the flds Admin. frequent feeding high in observe for HPN & CHO. Hormone Replacement Therapy High in CHON. Anorexia.88 Of Adrenal Gland and or Auto Immune Reaction S/S: Dec Bld Sugar (hypoglycemia) INC BP. NA ALL S/S OF CUSHINGS Dec Na (hyponatremia) DEC K + EXCEPT HYPERGLYCEMIA Dec BP Moonface. Fatigue. edema  Use of Table salt tablets (if Rx) or ingestion Surgery – prepare pt if cause . Polydipsia Depression Cardiac Arrythmias – due COMPENSATORY of MSH – Inc w/cTrunkal Obesity / thin Extremities to dec K Leads to “Bronze-Like Skin Pigmentation” Hypertension Decrease Resistance to Infxn Hypotension. Muscle weakness Nausea. Hirsutism. Vomiting Hx of frequent Hypoglycemic Rxn Lab Data : Decrease Cortisol Level Increase Cortisol Level Hypokalemia – due Hyponatremia Hypernatremia metabolic Alkalosis Hypoglycemia Hyperglycemia Inc Urinary Aldosterone Level Hyperkalemia Hypokalemia Decrease K Nsg Dx : Fluid Vol. weigh Daily MIO & weigh Daily (aldactone) & K supplements As Rx  Provide small. Inc K  Prevent exposure to Infxn Protect client exposure to Infxn  Provide rest periods – prevent fatigue Minimize stress in environment Administer SPIRONOLACTONE  Monitor I & O. stress. trauma. shock administer flds to treat vascular collapse IV glucocorticoids .89 Of salty foods (potato chips) or hyperplasia if experiencing Inc.Lysodren and Cytodren . report s/s of Addisonian Crisis – THYROID severe HYPOTENSION  Avoidance of strenuous exercise esp Meds: FOR LIFE in HOT WEATHER Glucocorticoids Synthesis Inhibitors . Basedow’s or Parry’s Dses Children: Cretenism EXCESS Main Problem: Slowing of metabolic process caused by hypofunction of the Secretion of excessive amount of Thyroid Thyroid Gland with decrease thyroid hormone secretion (T3 & T4) Hormone in the blood causes in the INC Of metabolic process DEFICIENCY in T3 and T4 Excess in T3 and T4 Causes:  congenital  surgery autoimmune genetic . sweating by pituitary tumor Post Surgery: poor wound healing.deposit Ca @ bones DEFICIENCY HYPOTHYROIDISM HYPERTHYROIDISM Adult: Myxedema Grave’s Disease.prevents formation of Gluco… ADDISONIAN CRISIS severe exacerbation of Addison’s dses caused by acute adrenal insuffieciency causes: strenuous activity.responsible for maintenance of METABOLISM .Solu-Cortef and Vasopressors Maintain strict bed rest and eliminate all forms of stressful stimuli MIO and weigh daily Protect client from Infxn Other Hx teachings: same with Addison’s T3 & T4 Calcitonin . infection. failure to take RX Meds s/s: PI : severe generalized muscle weakness severe hypotension hypovolemia. THYROID SUPPLEMENT Admin AntiThyroid Meds – for LIFE Synthroid. and intake of iodine rich foods and test using iodine – eg IVP can invalidate the test S/S : FACIAL EDEMA EXOPTHALMUS INTOLERANCE to COLD (+) Goiter DECREASE v/s Hypermetabolic State DECREASE GI Motility – constipation INTOLERANCE to HEAT HYPOactivity Increase Sleep – hypersomnia INC GI Motility . Maintain vital funx: correct hypothermia – maintain Quite & relaxing Activity adequate ventilation d.. Increase flds and high fiber foods to prevent constipation. minimal uptake may indicate – hypothyroidism). dry sparse hair.performed to determine thyroid function (increase uptake – indicated hyperthyroidism. brittle nails HYPERactivity NSG DX : Activity Intolerance – due to Fatigue Risk for Injury (bec of hyper) (fatigue – due to hypometabolism) Inc V/S PI : Promote a EUTHYROID STATE same WT LOSS even INC Appetite Warm smooth skin. restlessness.DIARRHEA Wt Gain in the presence of Dec Appetite Insomnia Dry scaly skin. agitation LAB DATA : Check TSH (increase) DECREASE TSH DECREASE T3 & T4 INCREASE T3 & T4 DECREASE RAIU (131) INCREASE RAIU INCREASE Serum Cholesterol Level RADIOACTIVE IODINE UPTAKE administration of 123I or 131I orally. PTU & Lugols s/e: insomnia. CHON. warm environment Provide a COOL ENVIRONMENT e. DIET: low calorie Assign to private room away from excessive activity c. Admin stool softener as Rx DIET : High in CHO. (RAIU) – HOW : a. fine soft hair Pliable nails Irritability. Meds: thyroid hormone replacement – take daily Vit & Minerals w/ supplemental dose in AM to avoid insomnia feedings bet meals & at HS Monitor THYROTOXICOSIS – tachycardia NO STIMULANTS . nsg consideration : take a thorough history – thyroid meds must be D/C 7-10 days b4 the test – meds containing iodine cough preparations. Provide comfortable. palpitation nervousness b.90  autoimmune tumor . Cytomel – lifetime ex. CALORIES f. hyperthermia . diarrhea.report diarrhea &  . vomiting. To check.  MEMORRHAGE – whether the dressing is dry or intact – its not a confirmatory that there is no bleeding. nausea. Antithyroid Drugs – Prophythiouracil and Tapazole . .  TETANY – due to decrease in CA – characterized by: . Chvostek’s Sign – facial muscle twitching on percussion of facial nerve c.it decrease size and vascularity of thyroid gland. H2O or orange/ apple juice. Radioactive Isotope of Iodine (131) – Radioactive Iodine Thrapy . dyspnea Protect eyes w/ dark glasses & artificial tears Monitor for AGRANULOCYTOSIS (fever. 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.can be diluted w/ a. Prepare pt for surgery – 2wks before SURGERY give LUGOL’S SOLUTION . Trousseau Sign – carpopedal spasm . metallic state Meds: a.given to destroy the thyroid gland thereby decreasing Thyroid hormone production COMPLICATIONS OF THYROID SURGERY: THYROID CRISIS – due to rebound hyperthyroidism Increase thyroid hormone Increase HRate/palpitation Inc Temp .toxic effect include AGRANULOCYTOSIS b.91 Palpitations. tremors.block synthesis of thyroid hormone.give w/ straw to avoid staining teeth. Sore throat & skin rashes) – if taking antithyroid meds. Sweating. slip your hands at the back of the neck (bec of principle of gravity)  Damage Laryngeal Nerve – to assess. tingling sensation – fingers & lips b. Diet: Inc Ca – spinach. seafoods calculi of having INC Ca d.92 Lab Data : Decrease Ca Inc Ca (N 4. Tracheo set – deu to dec Ca – Laryngospasm Diet. sardines. Increased secretion of PTH that result Or caused by accidental damage to or removal in altered state of Ca.5-5. Keep Ca supplement at Bedside Inc Oral Fld intake – due to renal c.5 mg/dl) Serum Phospate Inc Dec Serum Phospate Level Skeletal Xray – reveal Inc Bone density xray –reveal Bone Demineralization Nsg Dx : RISK FOR INJURY same PI : a. Low Ca Surgery – if due to tumor . b. Safety same PARATHYROID Parathormone Deficiency Inc CA in the Blood EXCESS HYPOPARATHYROIDISM withdraws Ca @ bone to the bld HYPERPARATHYROIDISM MP : Dec Ca (hypocalcemia) maybe hereditary. Phospate & bone Of parathyroid glands during surgery eg thyroidectomy metabolism S/S : Initial S/S: Bone Pain (esp Back Bone) Tingling lips & Fingers Disorder – kidney stones Chvostek’s renal colic Trousseau Constipation Late S/S personality changes cardiac arrythmias muscle pains Kidney NAV. GENITO-URINARY General Consideration  when performing assessment of Genito-urinary system.  rapid & deep breathing that occurs in diabetic pt is indicative of – KETOACIDOSIS  a pt is to receive NPH Insulin at 8AM.  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”. w/c of the ff statements made by the mother indicates a need for further instruction – “my child loves to drink milkshakes” – chon. Consideration for Pediatric Patient   assess for history of sorethroat. bladder capacity increase with age infants – about 65ml . the expected outcome is – Dec HR. the nurse anticipates that the doctor will most likely order – Ca Gluconate.93 TIPS FOR ENDOCRINE  a child w/ PKU was admitted.  a common manifestation of HYPOGLYCEMIA – shaky tremors.w/c has INCREASE Phenylalanine.  explain the meaning of terminologies.bec some pt are not comfortable talking genitals.  ask the patient what symptoms bother him/her the most.  what would be the question to support the Dx of Hypothyroidism – do you tire easily?.  w/c of the ff if manifested by a child could be indicative of diabetes – bed wetting. when shld the nurse expect to have hypoglycemia – in the late afternoon.  to determine the effect of PTU.  a pt post thyroidectomy develops tetany. use open-ended question. if INCREASE . characteristic of urine: color N . frequency urgency hesitancy Reportable s/s :  peri orbital edema  BP  Oliguria  Hematuria – Early Stream Hematuria – indicate lesion at Urethra Late Stream – indicate lesion at bladder WILM’S TUMOR congenital tumor at the kidney common in L Kidney and children below 5 yo S/S : Unilateral Abdml Mass Hematuria HPN Lab Data : CT Scan IVP NO INAVSIVE LAB/ Procedure NO BIOPSY Key points : a. Insipidus DECREASE – D. Mellitus Nsg Dx : Knowledge Deficit Risk for Injury PI : AVOID/ NO ABDOMINAL PALPATION Prepare pt for Surgery and Chemotherapy NEPHROTIC SYNDROME AGN . check for wt gain if >1lb/day – indicative of fld retention b. bladder trng comes after bowel trng – 15-18 mos of age) S/S common to all Disorders of GU: a. gravity (N 1. b. d. c. e.94 toddler – 300-400 ml school age – 800 – 1000 ml  infants are unable to concentrate urine until the age of 1 – therefore – adequate milk intake if baby has 6-8 diapers /day. Increase glucose – UTI Elevated CHON – Nephrotic Syndrome or PIH Epispadias – opening at DORSAL portion Hypospadias – opening at VENTRAL portion  bladder sphincter control develop at around 2 yo (therefore.010 – 1.amber if pinkish – bldg brownish – flagyl orange – rifampicin c.025) .D. s. <10 mg/ 24hrs urine Tea CYSTITIS Infection of the bladder Ascending infection caused by E. . Low Na CHON and Na LOW Turn Patient frequently – because pt w/ edema are prone to skin integrity like pressure sore formation S/S EDEMA: Peri-orbital Edema but subside Periorbital but progresses to generalized at the end of the day end of the day BP : at the Decrease or N INCREASE BP URINE : Frothy colored or Cola colored or Smoky LAB DATA (+) Proteinuria.95 MP : Altered Kidney Funx related to inability to retain CHON Destruction of Kidney Tissues related (therefore there is PROTEINURAI) to Group A Beta Hemolytic Streptococus DIET : causes: Autoimmune sorethroat congenital POSITIONING : INCREASE CHON. severe . Coli (from feces) or Pseudomonas RF : Nsg Dx : Fld Volume Excess Impaired Skin Integrity PI : Check BP Maintain Fld Balance Meds : NO Antihypertensive Antihypertensive (+) Steroids Diuretics (+) Antibiotics Wearing silk underwear (does not absorb moist).>10mg in 24 hrs (+) Proteinuria . URGENCY & HESISTANCY + Burning sensation on urination (dysuria) LAB DATA : Urinalysis – to check for microorganism Nsg Dx : Altered Elimination Pattern .use COTTON Bubble bath Prolong driving Common in FEMALE – due to size (short) urethra S/S: FREQUENCY. Meds : Diuretics Amphogel – to promote excretion of Cardiac Glycosides – Digitalis Phospate Fld .decrease urine output that is less than 400 ml/24hr (OLIGURIA) There will be INC BUN & Crea . effective : (-) pain) Diet : ACID-ASH DIET – give lemon juice or VIT C Hx Teachings: Avoid bubble Bath No Silk underwear Inc.Inc urine output (4-5L/day) All s/s + Anemia & HPN . AGN  Post-Renal – those that causes obstruction eg.96 Infection PI : Treat for Infection – antibiotics for 10-15 days Bladder Analgesic (ex. Fluid restriction. Fld Intake RENAL FAILURE ACUTE CHRONIC MP OLIGURIC PHASE .Dec Na & K ESRD RECOVERY PHASE .renal funx normalizes (1-2 yrs) Azotemia & Uremia – accumulation of waste products Sudden or Acute. restriction B. PYRIDIUM – ch can cause ORANGE COLORED URINE. Usually Reversible loss of IRREVERSIBLE kidney damage that Kidney Funx leads to scar formation “uremic frost” – skin pruritus LAB DATA There is inability of kidney to maintain fld & E balance Causes PHASES : Nsg Dx  Pre-renal Factors – those that dec bld circulating vol.Dec NA & Inc K RENAL FAILURE DIURETIC PHASE . Phase I: RENAL INSUFFICIENCY  Intra-Renal – dses condition of the kidney eg. – SHOCK. Kidney stones Polyuria Nocturia Polydipsia Phases of ARF PHASE II : MILD RENAL DAMAGE Increase BUN and same Crea – most sensitive Index Fld and E Imbalance Fld & E Imbalance Activity Intolerance PI : TO CORRECT THE IMBALANCE A. 2. FEVER. HPN .. vomiting. DIALYSIS ENCEPHALOPATHY – due to aluminum toxicity s/s: (+) dementia gloves. TENDERNESS. hesitancy and urgency Semi-permeable membrane: Abdomen (peritoneum) Dialyzing machine Use of Tenchkoff Catheter fistula or shunt Use of LAB DATA: Digital rectal exam – once a yr for pt 40yo and above Teachings: anastomosis of artery & vein (internal access) – less prone to infxn    Report Infxn (abdomen: rigid. ky jelly position: Sim’s Nsg Dx : Altered Elimination Pattern PI : Prepare pt for surgery  TURP – no incision  Suprapubic Prostatectomy  Retropubic -do Perineal -do.REPORT DIALYSIS BPH - PERITONEAL HEMODIALYSIS glandular enlargement of the prostrate common in males above 40 yrs old S/S : Decrease size and force of urinary stream Nocturia Frequency. seizures 1. headache CNS . Ff up check up (if INC ACID PHOSPATASE: Prostate CA) .97 Antihypertensive Inc RBC synthesis C. NO LONG DRIVE/ SITTING. DIET : Low CHON – NO PMS same Epogen – Diuretics AntiHPN Diet: muscle abnormalities – twitching seizures RENAL TRANSPLANT – s/s of complication : FLANK PAIN.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. Solution : cloudy) Check BT and CT external access Check Temp of dialyzing solution (more prone to infxn) Complications of dialysis (report ASAP): DISEQUILIBRIUM SYNDROME – due to rapid removal of solutes (electrolytes and CHON) s/s: GI – nausea.convulsion.  To prevent cystitis.  In a pt with BPH.  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. w/c of the ff is appropriate action – turn pt to side.  After peritoneal dialysis. the nurse shld expect that the pt will probably have the symptoms – residual urine of more than 50 ml. Consideration to Pediatric Patients .98 TIPS FOR GENITOR-URINARY  A common sign of ARF – OLIGURIA.  A male pt has an arteriovenous fistula in his L forearm.  Explain the methods of assessment to the patient. w/c of the ff the nurse must instruct to the pt to do – take a bath using the shower rather than bubble bath. w/c behavior would indicate that the pt needs further instruction in self care – he wears a watch on his L wrist. 2005) EENT General Consideration  Explain to the patient there there will be no or little discomfort when performing EENT exam.  w/c of the ff indicates complication of peritoneal dialysis – cloudy dialysate DAY 8 (Feb 11. Objective – “the room is spinning” Subjective – “I feel that I am revolving/rotating”   Hearing Loss Pain – if pain subside or (-) – rupture of ear drum Absence of pain indicates rupture of Tympanic Membrane – ear drum Lab Data : OTOSCOPY – revealed – reddened. Tract Infection S/S : PAIN – Pulling Tugging Crying when lying on the affected ear congenital tumor of the retina. buzzing or sea shell sound in the  ear  VERTIGO . bulging tympanic membrane Nsg Dx : Infection Sensory – Perception Alteration PI : Treat Infection (antibiotics – 7-10 days) – if does not heal – possible MYRINGOTOMY Hx Teaching : RIGHT POSITION while feeding Keypoints for Assessment   Note for abnormal findings Document the subjective and objective complaints OTITIS MEDIA RETINOBLASTOMA - FEMALE) infection of the middle ear RF : Faulty feeding practices Swimming in dirty waters Upper Resp. autosomal dominant (common in MALE and S/S : LEUKOCORIA – “cat’s eye reflex” .ringing. genetically transmitted.99  Obtain feeding history (bec the type & techniques differs)  Obtain the diet hx of the pt and hx to URTI  Involve the parents in the assessment of the baby Reportable Signs and Symptoms TINNITUS .whitish or grayish discoloration of the pupil Diplopia and or Strabismus LAB DATA : PE Opthalmoscopy . COUGHING. LIFTING.those with D. to Diabetes Rel. Chromosomal Abberation . (No Bowling & shampooing of hair at sink) RETINAL DETACHMENT MP : There is separation of sensory and pigment portion of the retina – therefore it will allow fluids to go in between which give rise to OUSTANDING manifestation as:  REPORT SUDDEN eye pain – indicative of bleeding/ hemorrhage VISUAL FLOATERS – pt says: “I see light structures Curtain like Floating spots Cobwebs” S/S : NO Pain Blurring of vision – because of floaters GLAUCOMA MP : INCRASE IOP due to obstruction in the outflow of acqeous humor or could be related to forward displacement of the iris. the Familial Predisposition Rel. to detached retina portion will be attached thru scar formation. to Steroids Rel.100 Nsg Dx : Knowledge Deficit Lab Data : Opthalmoscopy Tx : Surgery – Inoculation – done b4 age of 3 (chemotherapy – after surgery) Genticist Nsg Dx : Risk for Injury PI : Immediate Bed rest – AFFECTED SIDE TOWARDS THE BED – to allow the connection of DETACHED PART RETINAL DETACHMENT CATARACT RF: Aging (above 40) Aging (above 70) Related to trauma Related to Trauma GLAUCOMA NO SUDDEN HEAD MOVEMENT AVOID reading (TV – ALLOWED) Aging (above 40) Prepare Pt for Surgery: SCLERAL BUCKLING – use of laser to reduce inflammation and Common in Blacks when inflammation subside. TREATABLE but NOT CURABLE . Syndrome are prone POST SURGERY :  AVOID activity that requires BENDING. Administer MIOTICS (Pilocarpine.as high as 50 Gonioscopy Opthalmoscopy Perimetry – measures visual field    CATARACT MP : Opacity of the Crystalline Lense S/S : Blurred Vision (Poor Color Perception) NO PAIN LAB DATA: Nsg Dx : PI : Risk for Injury TO DECREASE IOP How: a. At lower conjunctival sac a. SLIT LAMP TEST – test for red light reflex (this reflex is absent in cataract pt due to presence of milky white lens) b.Out-patient only (use of laser only) TRABECULECTOMY – requires hospital admission for 1-2 days S/S : TUNNEL or Gun Barrel Vision – wherein there is loss of Peripheral Vision Hx Teachings : same w/ retinal detachment Halos around lights – rounded rings around eyes CLOSED ANGLE GLAUCOMA – (+) pain OPEN ANGLE GLAUCOMA – minimal or (-) pain LAB DATA:  Tonometry – measures IOP (N12-21) – PAINLESS ACUTE G Chronic G – as high as 25. . Diamox) – for LIFE it decrease the production of ACQEOUS HUMOR – admin.101 If Obstruction related : OPEN ANGLE. Prepare pt for Surgery : TRABECULOPLASTY – a new pathway was created for the passage of the blocked fluids. could lead to CHRONIC If due to Forward displacement: can lead to ACUTE CLOSE ANGLE b. Opthalmoscopy Nsg Dx : PI : Risk for Injury Prepare for SURGERY . . Tomolol. since same Coughing AVOID . DSES) Lab Data: same Caloric Stimulant test Weber’s test – ECCE – removal of anterior part lateralization of sound Rinne’s – bone ICCE – removal of entire capsule conduction Audiometry (above test –  PHACOEMULSIFICATION . Detachment MENIERE’S DSES OTOSCLEROSIS (hardening stape of the ears) RF : High altitudes Aging Ototoxic Drugs Aging S/S : Tinnitus LOW NA (AVOID – Alcohol & Caffeine containing Meds : AntiVertigo – Diamox.102  CATARACT EXTRACTION – Extra Capsular Cataract Extraction (ECCE) Intra Capsular Cataract Extraction (ICCE) Hearing Loss + VERTIGO (only for M.driving Blowing of Nose PMS Sudden Head Movement Bending . Bonamine Post Surgery Hx Teachings: MP : Cause by an imbalance of EndoOvergrowth of the stapes Lymphatic Fluids in the inner ear Sensori-neural hearing loss – since Conductive Hearing Loss Inner ear was affected middle ear was affected DIET : food) Effective : (-) Vertigo/ Falls AVOID – diving Small airplane .needle is inserted to lens and send vibration thereby crushing the cataract then suction it out use of TUNING FORK)  PERIPHERAL IRIDECTOMY – a whole is created then suctioning Nsg Dx : Risk for Injury Perceptualalteration Sensory PI : SAFETY Communication (to prevent pt from falling: bedrest or supine – danger of falls) Surgery : STAPEDECTOMY – mobilization of Establish Post Cataract Surgery – NO SEX for 4-6 weeks Health teachings – same w/ R.  Post Cataract Extraction : how shld the nurse position the pt – UNAFFECTED SIDE to minimize edema.  w/c of the ff is a common Retinoblastoma – Cat’s Eye Reflex. 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 . GASTROINTESTINAL  w/c Nsg Dx is considered a priority for a pt with Meniere’s Dses – Risk for Injury  a Tonometer is used for the purpose – to determine IOP.103 TIPS FOR EENT  A pt who underwent cataract surgery w/ intraocular implantation is scheduled for discharge. the nurse shld instruct the pt to do w/c of the ff when pain occurs – notify the AP. manifestation of  The parents of the pt w/ retinoblastoma must be referred to .GENETICIST GENERAL CONSIDERATION Provide privacy Ask the pt when he 1st notice the S/S Eg. 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.usually asso w/ NORWALK (common in ship). Tachycardia. “bruit” – abnormal vascular sound w/c indicate abdml aortic aneurysm SPHINCTER DIARRHEA/ AGE S/S: vomiting .N 5-35 bowel sounds/min) to assess.damage to mucosal lining of lower esophageal mucosa w/c can lead to esophageal CA   LAB DATA : Upper GI Series (Ba Swallow) Gastroscopy Esophagoscopy Stool Exam – to check for bacteria do do do Nsg Dx : Altered Nutrition Less Than Body Requirement Flds & E Imbalance PI : LAB DATA : Hear-  Insure Adequate Nutrition Position: Place pt in UPRIGHT – to avoid vomiting .NON-BILE-STAINED burn due to Reflux of Acid . use DIAPHRAGM of Steth – to listen for normal sounds BELL part of Steth – to listen for abnormal bowel sound Nsg Dx : Diarrhea Fluid Volume Deficit PI : Place pt on ENTERIC ISOLATION PRECAUTION (handwashing & gloves ONLY) – while waiting for lab result CHALASIA GERD Ex.104 Tarry Stool – indicates bldg (upper GI) Fever. it will progress to shock – due to K loss (hypokalemia) CONGENITAL WEAKNESS OF THE CARDIAC Complication : METABOLIC Acidosis same BARRETT’S ESOPHAGUS same . Dehydration – indicative of SHOCK Hypotention KEPOINTS… Bowel Sounds (check all 4 quadrants. 30 ML CLEFT LIP POISONING INTERVENTION: a.000 WBC Post Surgery: Non-fusion of (congenital) Palate . juice. water  Feeding : Thickened  Prepare pt for surgery : NISSINFUNDOPLICATION – part of fundus will be sutured to  NON-CORROSIVE – induce vomiting by stimulating GAG REFLEX How: a. b. c.if child is 15- . CALL poison control center. Syrup of Ipecac – administer w/ glass of H2O – make sure that all taken will be vomited – bec it is cardiotoxic (after 1hr – can repeat) dosage: ADULT esophageal area to tighten  Effective: if (-) vomiting and(-) reflux and heartburn CHILDREN – 15 ML . therefore X100)  Health teachings – crackers. MINIMIZE EXPOSURE – remove pt from the scene IDENTIFY the type of poison “if unknown substance was taken” – bring bottle or foil for proper identification MP: Non-fusion of facial process Palative Processess (soft & hard) (congenital) Nsg Dx : Altered Nutrition Risk for Aspiration Body Image Disturbance PI : Nutrition Safety Prepare for Surgery TYPES:  CORROSIVE – “DO NOT INDUCE VOMITING” Management: NEUTRALIZE the poison If STRONG ACID – give WEAK BASE (eg.105 (if BABY: use HARNESS or PRONE w/ HEAD UP POSITION)  Administer flds  Antibiotics/ Antidiarrheals ( dosage: if less than 10 kg.for 10wks old 18 mos 10 lbs 10gms/hgb 10. Use fingers or tongue blade b. ACID – give MILK) IF STRONG BASE – use weak ACID by using vinegar PALATE Surgery : Chiloplasty Uranoplasty . oats. rice. wheat AVOID GLTUEN RICH ALLOWED : Rice.there will be SEVERE DHN LAB DATA : Diagnostic Test : GLUTEN CHALLENGE – 3-4 mos – give gluten rich food And if there is malabsorption. AUDIOLOGIST & PSYCHOLOGIST PYLORIC STENOSIS congenital hypertrophy (“kumapal”) of the pyloric sphincter (bet stomach & intestine) S/S : PI : Nutrition Surgery – FREDET-RAMSTEDT or PYLOROMYOTOMY – incision at pyloric sphincter CELIAC DISEASE - GLUTEN –INDUCED ENETEROPATHY Genetic predisposition Life-time disorder MP :  PROJECTILE VOMITING (INITIALLY. NON-BILE STAINED but eventually it PROGRESSESS TO bile-stained) If sitting : 4-5 ft If lying down : 1 foot Feeding should be thickened then AFTER FEEDING.  ELBOW RESTRAINT – prevent child from touching the suture line.  FEEDING DEVICE – C CLIP – use dropper. cereals.  LOGAN BAR/ BOW – it decrease tension at suture line. place to RIGHT SIDE LYING SEATED at car seat – to facilitate the entry of food from stomach to duodenum  OLIVE-SHAPE MASS  VISCIBLE PERISTALTIC MOVEMENT – usually from L to R of the abdomen – w/c can lead to DHN LAB DATA : Ba Swallow – (+) “string sign” NSg Dx : Fluid Vol Deficit Fld and E imbalance Altered Nutrition Intolerance to GLUTEN OUTSTANDING S/S : Malabsorption Syndrome-crisis Abdl Enlargement – this can be triggered by INFECTION & Fld and E imbalance Anorexia Anemia . C PALATE – use Breck Feeder/ cup  Refer pt to: SPEECH THERAPIST.106  CRYING shld be minimize – bec it will put pressure at suture line. corn. soy beans . therefore (+) CDses Nsg Dx : Altered Nutrition PI : Dietary Modification : FOOD : Barley. 107 Commercially prepared cakes are made of wheat – AVOID Ok or allowed: if pt say “I will prepare a homemade cake” AVOID : spaghetti, macaroni, sausage, luncheon meat, hotdog INTUSSUCEPTION HIRSCHPRUNG’S DISEASE (AGANGLIONIC MEGACOLON) MP : There is telescoping of a part of a colon which leads to inflammation and edema MP : Absence of parasympathetic nerve fibers in a portion of a colon dilation, abdominal distention and pellet-like or ribbon-like stool. S/S : “sausage-shape mass” Abdominal distention “Dance sign” – the R lower portion of the colon becomes empty Vomiting : BILE-STAINED Constipation LAB DATA : Ba Enema: if for DIAGNOSTIC : it outlines the area involve if for THERAPEUTIC : it reduces intussuception by means of hydrostatic pressure Patient – meconium ileus & constipation – HALLMARK SIGN LAB DATA : BA Enema Nsg Dx : Altered Ellimination Diet : High Fiber Increase fluids Tx : Give Enema Nsg Dx : Diet : Meds : Laxative Surgery – SOAVE Surgery – resection with end to end pull through Tx : Constipation Altered Elimination Inc. Flds. High Fiber wonder drugs – steroid surgery TRACHEOESOPHAGEAL FISTULA (TEF) 108 MP : Failure of the esophagus to develop as a continous process Types :  AF1 esophagus NOT connected w/ abdomen/stomach  AF2 esophagus attached to trachea (when pt eat, it goes to the lungs)  AF3 stomach connects w/ trachea  AF4 stomach & esophagus connected  AF5 stomach, eso and trachea are connected  AF6 separated properly Atresia – “narrowing” Fistula – connection S/S : Excessive Drooling – danger in aspiration (avoid glucose water as initial feeding – use sterile H2O instead.) Coughing, Chocking Cyanosis LAB DATA : Lateral Neck Xray – to check the esophagus Nsg Dx : Risk for Aspiration PI : Safety Airway Keep child NPO – just give pacifier (if feeding OK – use sterile H2o instead NOT GLUCOSE) Tx : Surgery TIPS FOR GASTRO – PEDIA  w/c of the ff signs if manifested by a child post tonsillectomy needs to be reported – FREQUENT SWALLOWING;  a child who has had several episodes of diarrhea is likely to develop – metabolic acidosis;  in relation to dx of p. stenosis, w/c of the ff actions of the nurse is important – weighing pt daily for wt loss;  w/c of the ff will the nurse expect to observe in a child who loss fluid due to diarrhea – flushed dry skin;  the most appropriate feeding device for a child post cleft palate – paper cup;  the priority nsg care for a child on NPO is – offer a pacifier regularly;  a common manifestation of pyloric stenosis is – visible peristaltic wave;  the priority nsg dx for a pt w/ rotavirus infection is – diarrhea;  w/c of the ff is expected in a child suffering from celiac dses – intolerance to gluten PEPTIC ULCER 109 RF : Stress Smoking Salicylates or NSAIDS Helicobacter Pylori Zollinger-Ellison Syndrome (gastinoma) – tumor of the stomach – due to increase HCL acid GASTRIC DUODENAL RF : Nsg Dx : PAIN PI : Relief of Pain ESOPHAGEAL same Meds : ANTACIDS: Maalox – it NEUTRALIZE HCL Acid; RANITIDINE - it DECREASE HCL Acid; SUCRALFATE - it COATS the GIT same MP : Weakened Mucosa Excessive HCL Acid Common in Female in Male Below 65 above Inc risk for CA Common 65 yo & NO ASPIRIN Diet : vegetables BLAND DIET – NO SPICY, fried, raw fruits and (EXCEPT: avocado, banana & pineapple) OUSTANDING S/S: PAIN – aching, burning, gnawing GASTRIC SURGERY PAIN – 30mins – 1hr post meal 3hrs after meal PAIN at daytime Nightime Pain relieved by vomiting Pain relieved by eating 2- Also related as hyperacidity HEMATEMESIS (vomiting of blood) - severe bleeding – “shock” LAB DATA : GASTRIC Analysis (diamox blue – urine) Gastroscopy BA Swallow HgB Hct   (BII)  VAGOTOMY PARTIAL GATRECTOMY – Billroth I (BI) and Billroth II TOATAL GASTRECTOMY BI – gastrodoudenostmy – duodenum and stomach BII – gastrojejunostomy – stomach and jejunum COMPLICATIONS:  PERNICIOUS ANEMIA – due to decrease INTRINSIC FACTOR w/c came from stomach; 110  DUMPING SYNDROME (occur usually for 10-12 mos post surgery) – due to rapid emptying of the stomach and stimulation of gastro-colic reflex GASTRO-COLIC REFLEX – is usually due to increase CHO INTAKE in the diet . – Inflam of small & Specifically @ recto-sigmoid colon at DIVERTICULUM large intestine S/S : same same DIARRHEA (15-20x/day) 3-4x/day bloody mucoid diarrhea & constipation FEVER (+) (+) (+) CRAMPY ABDL PAIN LLQ LLQ RLQ (Rigidity (REPORT ASAP) –sign of colon rupture) LAB DATA: BA ENEMA Colonoscopy Stool Exam INFLAMMATORY BOWEL CONDITION ULCERATIVE COLITIS CROHN’S DSES Nsg Dx : PAIN Altere Elimination: Diarrhea DIVERTICULITIS (Regional Enteritis) RF : With familial Predisposition Common in those LOW FIBER Diet Related to Genetics Smoking as Protective Effect Common in Aging Common in Obsessive-Compulsive Or Stress Related or to “perfectionist” PI : Relieve Pain Meds: Steroids Anticholinergic Antidiarrheals Antispasmodic DIET : Low Fiber and Low Residue – for Ulcerative and Chron’s . NO UPRIGHT SITTING AFTER MEALS S/S OF Dumping Syndrome : Diarrhea Diaphoresis Dizziness/drowsiness Management: NO FLUIDS after meals – instead in between meals DIET: High Fats – because it delays the emptying of the stomach LOW CHO Lie down – after eating MP : Inflammation @ large Intestine Inflam @ L Intes.NO PANCAKE. 111 Diverticulosis – High Fiber/residue – allowed: vegetables Low residue – (no vegetables) III Entire Area – manual reduction IV Entire Area – irreducible TYPES SURGERY : Colostomy – irrigate Ileostomy – no need for irrigation INTERNAL H – above the spinchter EXTERNAL H – below the spinchter Characteristic of N Colostomy – REDDISH or PINKISH EDEMATOUS MOIST N elevation from skin: 2.emerge up to pelvic area with ice pack at head to prevent dizziness STOOL SOFTENER SURGERY HEMORRHOIDS MP Varicosities of the ANAL SPINCHTER RF PREGNANCY PROLONGED STANDING PORTAL HPN – hepatic enceph and liver cirrhosis PANCREATITIS AUTODESTRUCTION OR AUTODIGESTION of the pancreas RF GRADE I Small Area II Large Area – reduces spontaneously #1 Alcoholism #2 autoimmune High Fat Diet Biliary Dses . Bag : 48hrs or 3x a wk Pruritus Pain Bleeding BEST TIME TO DO COLOSTOMY CARE – at home. while in the bathroom PAIN – use SITZ BATH (48 degree C – temp of H2o) STOP colostomy irrigation if patient (+) ABDOMINAL CRAMPS .5 cm Diameter : 5cm S/S LAB DATA Sigmoidoscopy Proctoscopy P Exam When to empty colostomy: when 1/3 – ½ full (EMPTY DO NOT CHANGE) Nsg Dx Altered Elimination PI Diet : High Fiber Avoid Spicy When to change C. FATS Increase Liver Fnx test USG Nsg Dx PAIN PI Relief of Pain meds : DEMEROL diet: LOW FAT PAIN Relieve PAIN Meds: DEMEROL – DRUG OF CHOICE AVOID MORPHINE – it causes more pain bec it will causes spasm to the spinchter of oddi DIET LAB DATA surgery : incision. COUGHING. CULLEN’S SIGN – pain w/ bluish discoloration @ umbilicus Forty flatulence S/S R UQ Pain radiating to R shoulder or R Scapula – usually precipitated by FATTY INTAKE GI S/S – NAV diarrhea and Jaundice URINE: dark colored NAUSEA & VOMITING SHOCK – as complication STOOL : “clay-colored” or grayish – alcoholic stool LAB DATA Elevated Serum Amylase (N56-190 u/L that normalize in 2 wks) Nsg Dx PI Increase AMYLASE. bladder RF Fat Female Fertile TURNING. CO2 insufflation LOW FAT AVOID alcohol 1) LAP. CHOLE – 4 small 2-3 days after – discharge pt and back to ADL 1 WK after – pt can lift weight CHOLELITHIASIS CHOLECYSTITIS Combine or usually come together in a pt 2) CHOLECYSTECTOMY – R SUBCOASTAL complication: “Pneumonia” – report rusty-colored sputum hx teaching: Stone in gall bladder Inflammation of the G. WBC.112 SS PAIN @ peri-umbilical area or epigastric that radiates to peri-umbilical area GREY TURNER SIGN – pain w/ bluish discoloration at flank area. DEEP BREATHING same . 2-4 wks w/ jaundice. Meds : HEPATOPROTECTORS DIURETICS a. b. ICTERIC . CHON. Alcohol and Drugs  STORES : Vitamins & Minerals Signs and symptoms PI Tx for Infection a. c. d. Diet : High Calorie Low Fat Increase Liver Funx Test Liver Biopsy . & clotting factors  METABOLIZES: CHO. POST ICTERIC . pt prone to bleeding.scarring of liver tissues TYPES Fecal-oral bld.2-4 mos s/s subside Lab data Increase Liver Funx Test (Inc AST/ ALT) Hepa A – Inc HaV Hepa B – HbsAg Nsg Dx Infection Alt Skin Integrity Body Image Disturbance BILIARY Due to alcoholism CHF due to Hepatitis CARDIAC Due to biliary Disorder POST due to S/S – are related to 3 FUNXs of the LIVER  MANUFACTURES : bile. body flds Post Hepa B Fecal-oral Non A & B (Hepa A & B Combination 2-6 wks 6wks-6mos 70-80 days 6mos LAENNE’S NECROTIC 6wks- STAGES OF HEPA B    PRE-ICTERIC .1-2 days : S/S NAVDA – NO jaundice yet. immunoglubolin. C.113 HEPATITIS MP Isolation : A & E – Enteric B. malnutrition – no cho metabolize edema – due to fld retention (bec of dec albumin) Flds & e imbalance LAB DATA b. Fats. D – Universal Inflammation of the Liver COMPLICATION Liver Cirrhosis TYPES A B C D E Infectious SERUM POST TRANSFUSION DELTA HEPA ENTERICALLY-TRANSMITTED LIVER CIRRHOSIS . 114 Nsg Dx Risk for Injury Fld & E imbalance Fld Vol Excess Altered Nutrition PI SAFETY HOW? Meds: Diuretics – due to fld retention ANTIHPN – due to portal HPN Clotting factors : Coagulants – give Vit K (to avoid bleeding) Increase abdl girth – “I cannot button my pants anymore” (fluids) management: abdominal paracentesis – aspiration of fluids from the peritoneum .complication: chance for infection & shock  Diet : LOW CHON or CHON to Tolerance Or High Biologic Value CHON – good quality CHON (eg poultry products)   SURGERY : Liver Transplant COMPLICATIONS: a.common s/e : DIARRHEA b.facilitate excretion of ammonia by acidifying the colon . scissors at bed side (Balloon Tamponade) . s/s : ASCITIS – accumulation of fluids at the abdomen wt gain pt preparation: #1 instruct pt to void. HEPATIC EBCEPHALOPATHY – accumulation of ammonia – toxic to brain s/s: PERSONALITY CHANGES DECREASE LOC or irritability/ restlessness DRUG OF CHOICE : Neomycin. Lactulose .effective if (-) hematemesis . #2 position: sitting the evaluate the WEIGHT. ABDL GIRTH & REPSIRATION effective if : Pt decrease wt of 5 lbs and decrease or N RR c. HPN BLEEDING ESOPHAGEAL VARICES – DUE TO portal Lab data Sengstaken Blakemore Tube – 48 hrs inflated.  which of the ff indicates a ruptured appendix – absence of pain.  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 . the nurse shld expect gastric drainage for the 1st 12 hrs to be – reddish brown.  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.  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”.  the priority nsg care post common bile duct exploration – preventing hypostatic PNA. w/c shld the nurse prioritize – Administration of Antibiotics. of ALL the ff written orders.  ff subtotal gastrectomy.115 TIPS GASTRO – ADULT  A pt w/ appendicitis was admitted. fatal and could even lead to death CONCUSSION – jarring of the brain. Stuff toys.INCOMPREHENSIBLE DECEREBRATE RIGIDITY 1 .NO . Your mom will be back after you have eaten your lunch. mother wallet Associate mother’s time w/ child activity (children has NO DEFINITE TIME) Ex. Assess for presence of URTI – could be sign of Meningitis. “na-alog” w/c could lead to s/s of LOC in 24-48 hrs DECORTICATE – abnormal flexion which indicates damage to the cortex s/s : PEDIATRIC CONSIDERATION a. Assess child for S/S of anxiety - bed wetting nail biting (N up to 4 yo) head banging excessive thumb sucking GLASGOW COMA SCALE EYE OPENING (4) MOTOR (6) VERBAL RESPONSE (5) 6– OBEYS COMMAND 5 – ORIENTED LOCALIZES PAIN 4 – OPEN SPONTANEOUSLY CONFUSED 4 – WITHDRAWS FROM PAIN 3 – OPENS TO VERBAL COMMAND INAPPROPRIATE 3 .NO RESPONSE RESPONSE 54– 3– 21 .DECORTICATE RIGIDITY 2 . Otitis Media d. c. Assess for their habits “security blankets” – ex. DECEREBRATE – more serious .116   #2 BEHAVIOR #3 REFLEX When assessing MUSCULO SYSTEM:    #1 Range of Motion #2 Joint Stiffness #3 POSTURES e. CONTUSSION – more severe.NO RESPONSE 1 . Hemophilus influenza.abnormal extension w/c indicates damage to brain stem b. Check for bowel and bladder funx – indicates neurological maturity 15-18 months – START BOWEL TRAINING 2 yo – start bladder training #1 Decrease LOC #2 widening pulse pressure (increase systolic BUT diastole is N) #3 Convulsion & seizures ABOVE ARE S/S OF INCREASE ICP.OPEN TO PAIN 2 . GLOSSOPHARYNGEAL X. V. FACIAL : SENSORY : sense of taste @ anterior 2/3 of the tongue pt is COMA and MOTOR CRANIAL NERVES I.6 cardinal direction of gaze VI. close eyes. MONITOR THE PT : VII.117 AND MOTOR : ability of pt to chew SCORE OF 3 : the one to pronounce NO response (DEAD) – Doctor will Reflex: CORNEAL REFLEX – (+) if both eyes can blink SCORE OF 15 : pt is awake Score of 8 : 7 and BELOW 50-50. ABDUCENS (if abnormal look for DIPLOPIA) gag reflex XI. ACOUSTIC or VESTIBULOCOCHLEAR . use cotton & needle and run across the cheek) HYPOGLOSSAL – TONGUE MOVEMENT . VAGUS SENSORY – Posterior Taste 1/3 Of The Tongue MOTOR .motor movement of shoulder muscle XII. OPTIC : SIGHT – snellen’s chart – 20/20 usually by age 3-6 yo IX. OLFACTORY : SENSORY Abnoxious smell : Facial Expression VIII.swallowing and III. OCCULOMOTOR IV. TROCHLEAR Eye movement . SPINAL ACCESSORY . observe for balance Anosmia – no smell Perfume II .Sense of hearing and balance : smell - TEST : ROMBERG’S TEST stand erect. TRIGEMINAL : SENSORY : FACIAL SENSATION responsible for (to check. Prognosis : complete recovery in 3 months Target: Mothers or FEMALES – bec they are the source of transmission Treatment : splint and cast for 3 mos – leads to nerve Ex.118 DUCHENE’S MUSCULAR DYSTROPHY (DMD) X –linked RECESSIVE (only mother transmit to SON) COMPLICATIONs young children Respiratory Paralysis – for Cardio-Resp. Fix (non-progressive) neuromuscular disorder characterized by abnormal muscle movement.lower plexus w/c leads to TX a. a) GOWER’S SIGN – inability to stand up . b.duck-like gait S/S c) impaired mobility d) difficulty in running and climbing Unknown Exaggerated Reflexes Protrusion of the tongue or tongue thrusting Early pattern of hand dominance Back Arching Scissors-gait . Aunt. Supportive . mothers.use arms to brace the body Cause b) WADDLING GAIT .50% chance LAB DATA Muscle Biopsy PExam Nsg Dx Ineffective Breathing Pattern Impaired Physical Mobility PI AIRWAY (keep TRACHEO at bedside) Daughter as Carrier – 25% chance DMD Erb Duchenne’s Paralysis (EDP) Klumpke Palsy (KP) Related to Birth Injuries affecting the BRACHIAL PLEXUS – nerves at axilla portion HEREDITARY EDP – upper plexus KP . Arrest - for adolescent (-) Father Mother (+ carrier) Son . Female Sibling. crutches Refer parents to geneticist paralysis. female members of the family – (bec transmission: X linked recessive) regeneration X-linked RECESSIVE DIRORDER CEREBRAL PALSY MP S/S characterized by progressive muscle atrophy w/c apparent in male at the age of 3 .Permanent.leg brace. the surgery is revised) .for fine motor – to open a bottle of soft drinks  PROJECTILE VOMITING  IRRITABILITY  ENLARGED HEAD – N Head Circumference : 3335 cm (chest circum: 31-35 cm)  SEPARATION OF SKULL BONES  SEIZURES  SUNKEN EYES – Can Progress To Bossing Sign  MACEWEN SIGN – crack pot sound upon knocking the head LAB DATA HYDROCEPHALUS NOT A DISEASE but a manifestation of an existing disorder CT Scan MRI PExam – focus on head circumference (tape measure – at bedside measure H Circumference) NSG DX PI Related to ARNOLD CHIARI MALFORMATION DANDY WALKER SYNDROME there is ELONGATION of the BRAIN STEM or Medulla . S/S OF HYDROCEPHALUS PI SAFETY a.119 LAB DATA Neurological Assessment PExam Nsg Dx Risk for Injury Impaired Physical Mobility From Lateral Ventricle it goes to Foramen of Munroe then to 3rd Ventricle then to Aqueduct of Sylvius then it moves to F. Meds : Anticunvulsants.200 ml) – Position in ICP Meds to Risk for Injury SAFETY Semi Fowler’s – to prevent increase Diuretics Anticonvulsants Surgery Ventriculo-Peritoneal progressive procedures Shunt – (AS CHILD AGE PROGRESSES. of Luschka and Magendie going to 4th Ventricle then it goes back to subarachnoid spaces of brain. Muscle Relaxants c. Refer child to : PT – for gross motor movement – walking OT . Prepare child for SURGERY – release of TENDON OF ACHILLES – to promote mobility d.characterized by ATRESIA of and it protrudes to Foramen magnum Foramen of Luschka & Magendie SIDE NOTES: rich in glucose FLOW OF CSF (N amt : 100. Leg braces b. b.at bed side) SB OCULTA NO SAC W/ DIMPLE or TUFT OF HAIR Bladder and Bowel Problem Paralysis of Lower Extremities Hydrocephalus (tape SB CYSTICA W/ SAC INCREASE ICP SUB TYPES:   ICP above 15mmhg (N 0-10) Mild elevation : 11 – 20 Moderate : 21 . DOUGHNUT ring SURGERY WITHIN 24-48 HRS SPINA BIFIDA – failure of a PORTION of spinal cord to fuse COMPLICATION TYPES Post Surgery Complication measure.120 Meningocele – w/ sac that contains CSF and meninges. 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.30 . c. Wet sterile gauze to cover the skin. Meningomyelocele – CSF. Position: Prone or side lying (NEVER SUPINE). b.sign of MENINGEAL IRRITATION LAB DATA Lumbar Puncture CSF Analysis Nsg Dx Infection Risk For Injury PI Safety Seizure Precaution Tx the Infection 3. Monitor Abnormalities – decorticate. INITIAL: Behavioral Changes – irritability. decrease LOC – drowsiness or pt becomes sleepy 2.121 Severe : 31 and above With the use of INTRAVENTRICULAR or SUBDURAL MONITORING DEVICE to monitor ICP RF MENINGITIS MENINGISMUS Hydrocephalus Space Occupying Lessions Brain Tumor Trauma Inflammation of meninges w/c could be related to Inflammation of meninges but WITHOUT the presence of bacteria esp the H. decerebrate Nsg Dx PI Risk for injury To decrease ICP Head of Bed ELEVATED Evaluate Neuro Status – Glasgow AIRWAY Discharge Meds Instruction Anticonvulsants.flexion of neck would lead to flexion of lower ext. Steroids.enteric precaution MEDS Antibiotics  For Bacterial Meningitis . Bacterial Meningitis – respiratory of droplet precaution Viral Meningitis .refer to AUDIOLOGIST . Vital Signs Changes – widening pulse pressure DECREASE RR and PR INCREASE temperature S/S of INC ICP + Kernig’s Sign – pain on extension of lower extremities + Brudzinkis . disorder S/S 1. Diuretics (mannitol – to dec amt of cerebral edema)  Seizure precaution – DARKENED ROOM     Type of Infcetion: a. Vomiting 4. Influenza.may cause hearing impairment . and infection Neisseria Meningitidis Usually accompany w/ resp. restlessness. . COMPLETE STROKE – there is FOCAL s/s if R side of Brain Affected – L Eye . DEPENDS ON THE PROGRESSION a. b. non recurring but TOXIC ENCEPHALOPATY and HEPATOPATHY (CNS) (LIVER) RF Presence of Viral Infection Use of Aspirin TRIAD S/S Fever Impaired Liver Funx Impaired Consciousness w/c could lead to convulsion STAGES I II III IV V pt becomes lethargic confusion decorticate rigidity decerebrate rigidity seizure or coma LAB DATA Bleeding and Clotting Time Liver Biopsy Neurological Assessment Nsg DX Risk for Injury Altered Thought Process Altered Thermoregulation Impaired Physical Mobility PI Treatment – symptomatic – assess neuro status Bleeding – give Vit K AVOID ASPIRIN when there is VIRAL INFECTION MP     Decrease Oxygen to brain cells TYPES THROMBOSIS EMBOLISM HEMORRHAGE INFARCTION RF atherosclerosis hpn obesity smoking stress age/ gender SIGNS & SYMPTOMS: 1.122 REYE’S SYNDROME CVA/ STROKE Non inflammatory. RELATED TO LOBES . pt is N). STROKE IN EVOLUTION – there s/s like: facial paralysis Muscle weakness .above s/s could last 2-3 days c.R Face – L Body if L Brain – R Eye – L face – R body 2. TIA – brief period of neurologic dysfunction that last less than 24 hrs (between episode. 123  FRONTAL – if affected – PERSONALITY CHANGES – BROCA’S AREA (expressive aphasia – mouth opening). Emotional Lability SAFETY Low Na and Cholesterol Activity Range of Motion Exercises Surgery Craniotomy Infratentorial Cranio – FLAT Supratentorial . .memory disturbances – WERNICK’S LANGUAGE AREA (choice of words.  PARIETAL .  mgt: talk to pt slowly Dysphagia swallow twice to prevent aspiration instruct the pt to LAB DATA Increase Cholesterol Diagnostic Test CT Scan MRI EEG OCCIPITAL .RECEPTIVE APHASIA).VISUAL disturbances Nsg DX care half of the body Unilateral Neglect – inability to Impaired Physical Mobility Risk for Injury PI 3. understanding . Hemiphlegia paralysis of one side “mood swing” Aphasia Expressive – inability to find right words to say (damage to Brocka’s Area).  TEMPORAL .Semi- fowler’s . SIGNS AND SYMPTOMS INDICATIVE OF COMPLICATIONS Hemianopsia loss of half of the visual field (eg.pt can say right words – mgt: picture board and Receptive inability to understand spoken words (Wernick’s area) Position Semi-fowler’s Elevated Meds Antihypertensive Diuretics Antilipimic Agents Anticonvulsants Thrombolytics – if (+) thrombus – to dissolve clots DIET of the body. Pt consumes half of the food at plate).DISORIENTATION – especially SPATIAL orientation. depression therefore. Common in Male and Female  NO gender related factor but could be related to viral infxn Early onset : 20-30 yo (Female)  Reversible Early onset : above 50 yo (male) MP Inflammation that leads to destruction of Peripheral Nerves Deficiency in ACTH Receptor Sites – 90% w/c leads to: ASCENDING GBS Or Def.due to under medication or lack of meds. Diplopia and Ptosis – which Nsg Dx Ineffective Breathing Pattern (ALL) same PI AIRWAY (tracheostomy – bed side) – ALL same MEDS Steroids Neostigmine – ATSO4 .#1 Clumsiness that eventually lead S/S Muscle weakness w/c begins at face muscle weakness & resp.  Cholinergic Crisis (CC) .due to over medication – overdose Signs and symptoms of above complication: MUSCLE WEAKNESS – in MC due to ACTH Deficiency while in CC due to or as adverse effect of the drug to progresses to MASK-LIKE face which lead to respiratory depression (descending paralysis – start at face – “NO telebabad”) Treatment : TENSILLON – effective in MC – it INCREASE MUSCLE STRENGTH Effect in CC – it worsens muscle weakness once given – give ATSO4 NEOSTIGMINE – for MC as TREATMENT . PULMOLOGIST and PT MYASTHENIA GRAVIS COMPLICATIONS  Myasthenia Crisis (MC) .antidote Avoid crowded areas : viral infection Refer to NEUROLOGIST.124 DISEASES OF NEUROMUSCULAR Barre Syndrome (GBS) : Guillain LAB DATA CSF – Increase CHON TENSILLON TEST – 5 mins (to all neuromusco disorders) Myastenia Gravis (MG) Multiple Sclerosis (MS) Amyotrophic Lateral Sclerosis (ALS) GBS MG  Descending paralysis – start @ upper ext. in ACTH – “neurotransmitter” DESCENDING GBS Mixed Type GBS ASCENDING GBS . “I know I will be eventually confined in the wheelchair The muscle weakness – will eventually lead to RESPIRATORY DEPRESSION s/s of generalized muscle weakness: FACIAL – diplopia Impaired Cerebellar Funx LABDATA CSF – Increase CHON EMG – “contract and relax” – needle insertion Muscle biopsy Ataxic Gait – “lasing” Impaired Sensation – NO HOT/COLD BATH NSG DX Ineffective Breathing Pattern PI AIRWAY (tracheostomy) SUPPORTIVE Refer to Geneticist Impaired Sensory Funx – impotence LAB DATA #1 MRI – specific test for MS – it localizes the area of plaque formation or the area of dyemlination #2 CT SCAN NSG DX same with GBS & MG DRUGS STEROIDS Anticonvulsants – dilantin Muscle relaxant – Baclofen Bladder Stimulants – Urecholine (bethanicol) HX TEACHINGS AVOID : HOT COLD SHOWER Refer to PT: ROM Exercises SIDE NOTES: A Recessive : Cystic Fibro. Apalstic/Fanconis – either or both parents are (+) for trait NOT DSES A Dominant : Retinoblastoma. Cord AMYOTHROPIC LATERAL SCLEROSIS related to TRAUMA . Genetically Transmitted: AUTOSOMAL DOMINANT – common in Male & Female More Pronounce is DYSPHAGIA Eg. Color Blindness.125 (LON GAHRIG’S DISEASE) MULTIPLE SCLEROSIS Common among women – especially white There is destruction of MYELIN SHEET at CNS . ALS – either father or mother (+) for disease or trait X Link Recessive : Hemophilia. Sickle Cell. Duchennes Muscular. therefore generalized muscle weakness MP Destruction of Upper and Lower Motor Neurons. G6PD Dses – mother (+) trait NOT DSES and transmit to SON SPINAL CORD INJURY Destruction of S. 126 TYPES CERVICAL 8 – most serious – quadriphlegia THORACIC 12 LUMBAR 5 SACRAL 5 COCCYGEAL 1 PI SAFETY - immobilize, surgery LUMBOSACRAL AREA – if affected, therefore PARAPHLEGIA – bowel and bladder problem THORACIC - paraphlegia + bowel and bladder problem CERVICAL c1 – c4 - incomplete or partial quadriphlegia C5 – C8 - Complete quadriphlegia LAB DATA Myelogram CT Scan Xray      a. Nsg Dx Risk for Injury Impaired Physical Mobility PI SAFETY Immobilize the spine – side lying w/ pillows bet legs b. Surgery COMPLICATIONS OF SPINAL INJURY : AUTONOMIC DYSREFLXIA – due to full bladder and bowel s/s : #1 INITIAL : HPN #2 Diaphoresis #3 slight fever what to keep at bedside: CATHETER - TO KEEP THE BLADDER EMPTY, BEC IF FULL IT WILL TRIGGER THE ANS TIPS FOR NEURO  A 10 yo is to undergo EEG, w/c comment made by a pt demonstrate that she understands the procedure – “I will wash my hair after the procedure”;  A pt w/ tumor of the frontal lobe will most likely manifest – difficulty in concentrating;  A pt w/ M. Sclerosis has urinary incontinence. To achieve voiding, w/c nsg care shld the nurse give – establishing regular voiding sked;  While interviewing a pt. w/ Myasthenia gravis, w/c of the ff statements confirm the dx – “I have difficulty in swallowing”;  A male pt w/ CVA is observed by the nurse to have consumed half of his meal, the PRIORITY Nsg Dx – Unilateral Neglect;  When taking care of pt w/ C4 Spinal Injury, w/c equipment shld the nurse keep @ the b.side – Urinary Catheterization Set;  The PRIORITY NSG DX for pt w/ Myasthenic Crisis – Ineffective Breathing Pattern 127 MP Maldevelopment of the Hips – that involves the acetabulum, head of femur or both S/S MUSCULO CLUBFOOT DEFORMITY MP Congenital Foot twisted out of place Types LAB DATA Talipes Varus – “inversion” Talipes Valgus – “eversion” Talipes Equinus – “tiptoe” LAB DATA PE Xray Nsg Dx PI Extra Gluteal Fold – at affected side; Ortoloni’s Sign – (+) Click Trendelenburg Sign or Pelvic Dropping – when child stand in one foot toward the affected side, then there is change in length Alli’s Sign or Galleazi’s Sign – shortening of the affected leg click Ortolani’s – abduct leg sideward – (+) click Nsg Dx Impaired Physical Mobility Promote Mobility PExam Barlow’s Manuever – press leg downward – (+) Impaired Physical Mobility PI #1 Double or triple diaper – to keep legs in abducted position; #2 PAVLIK Harness - for 2-3 mos #3 Hip Spica Cast LAST RESORT #1 MANUAL MANIPULATION #2 SEREAL CASTING – every 1-2 wks til position normalizes #3 DENNIS BROWN SPLINT – 2-3 months CAST : assess for s/s of neurological damage: Capillary refill – if more than 3 sec. - REPORT NO ADDUCTION OF LEGS! EDEMA FRACTURES Skin Color/ nailbed CONGENITAL HIP DISLOCATION MP Break in the continuity of the bone TYPES Open (compound) – bone tears the skin – therefore open: risk for infection CLOSE – skin intact  AVULSION – tear in the tendon 128       COMMINUTED - fragmented COMPRESSED – crushed IMPACTED – driven to each other DEPRESSED – pressed SPIRAL – goes around the bone GREENSTICK – incomplete #1 Deformity #2 Pain #3 Edema #4 CREPITUS – sound created when two bone surface rob each other S/S NSG DX Impaired Physical Mobility PI MOBILITY – immobilize the fx a. Splinting; b. Casting – check for edema – elevate the affected areas; - check skin color – capillary refill time - check for presence of blood stained c. OUSTANDING S/S      Uneven Hemline; Uneven waistline; Uneven shoulder (+) Rib Hump Prominent Iliac Crest LAB DATA Bend Over test – instruct to touch the toes and note for rib hump Xray Nsg Dx Impaired Physical Mobility - child Body Image Disturbance - adolesence After cast, - CRUTCH WALKING  2 point gait – indicated if both lower extremities has partial wt bearing;  4 point gait – indicated for partial wt bearing;  3 point gait - indicated if 1 leg is allowed partial wt bearing and the other one is N;  swing through - when both legs need to moved past the level of the crutches  swing to – when both legs need to be moved AT THE LEVEL OF THE CRUTHES going upstairs – unaffected then crutch (goodleg – crutch – bad) going down – crutch then bad leg – then good leg SCOLIOSIS Lateral Deviation of the Spine STRUCTURAL – non correctible FUNCTIONAL - correctible MP RF TX a. To decrease curvature – wear BOSTON or MILWAUKEE Brace – for 23 hrs/day except bathing b. SURGERY – HARRINGTON ROD - LUQUE HX Teaching Avoid : Bending Jumping Rope Playing Tennis Trampoline Allowed: Brisk Walking Swimming brisk walking  MEDS : Ca Supplement .129 Cheer Leading OSTEOPOROSIS/ HUNGRY BONE MP Loss of Bone Density RF #1 smoking AGING IMMOBILITY MENOPAUSE – decrease Estrogen Secondary to Existing Condition – as secondary Hyperparathyroidism S/S PAIN Dowager’s Hump Short Stature Progressive Decrease in Height LAB DATA Nsg Dx Decrease in Calcium Bone Densinometry Bone Scan Xray SAFETY ARTHRITIS RHEUMATOID OSTEOARTHRITIS Common GOUTY FEMALE MALE/FEMALE Affected Part Upper Extremities Extremities wt bearing joint MALE Lower How? MP  DIET : High Ca especially 4 those with – OSTEOPOROSIS .seafoods .spinnach .   STAGE 1 – no Disability STAGE 2 – with Interference To ADL .bicycle reading . systemic inflammation of connective tissues Synovial joints and joints of Upper extremities S/S PAIN Inflammation Morning Stifness Stages of Rheumatoid A.sardines  ACTIVITY : Partial Weight Bearing (NO SWIMMING) – jumping rope .alendronate Fosomax – SIT UPRIGHT AFTER Chronic. incapacitation   Diet : Low Purine/ Purine Restricted: AVOID : Organ Meats SEAFOODS ULNAR DRIFT SWAN NECK DEFORMITY LAB DATA Decrease HgB Increase ESR Nsg Dx PAIN Impaired Physical Mobility PI a. MEDS : Relief of Pain ASA .130 STAGE 3 . Warm Bath. exercise: ROM Alcohol ALLOWED: Cheese (EXCEPT fermented and Aged) Increase ORAL Fluid Intake OSTEOARTHRITIS A degenerative joint disease that involves the weight bearing joints – elbows & knees S/S GOUTY ARTHRITIS PAIN – NO inflammation Bouchard’s Nodes (distal) Heberdene’s Node (proximal) MP Metabolic disorder of purine w/c leads to deposition or uric acid at joints site: THE GREAT BIG TOE LAB DATA S/S Nsg Dx PAIN Impaired Physical Mobility PI Weight Control - (+) PAIN – usually aggravated by pressure (+) Inflammation above s/s affects the LOWER EXTREMITIES LAB DATA Increase Uric Acid NSG DX PAIN Impaired Physical Mobility PI Relief of PAIN Meds : Allupurinol.Antiinflammatory STREROIDS c. Probenecid xRAY Health Teaching Hot or Cold Compress ASA Trunk Assistive Device (cane) SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) .with major compromise of funx STAGE 4 . b. What can the nurse advise the pt – you can hold on to the trapeze bar while moving.  post spinal fusion –ROBAXIN –is given for w/c of the ff purpose .131 Autoimmune multi system dses characterized by inflammation of connective tissues JOINT : stiffness. w/c action reflects a need for further instruction – the pt bears his/her wt with his/her axial. CARDIOVASCULAR : CNS : Irritability. treat Drugs Steroids  a pt on buck’s traction of the R femur ask the nurse how he can possibly move around.nfection prevention O – utput and input monitoring N – utrition S – kin Assessment  when assessing an infant. (+) morning TIPS FOR MUSCULO (+) chest pain.  a child has hip spica cast upon discharge. (+) s/s of dec LOC. LAB DATA Increase ESR  pt in russel’s traction is being taken cared of by the nurse. w/c of the ff needs to be reported – extra gluteal folds. Nsg Dx PAIN Altered Tissue Perfusion Risk For Injury  a pt is using CRUTCHES for the first time. TRACTION PRINCIPLES T – rapeze bar R – equires free hanging weights A – nalgesic C – iculation monitoring T – emperature monitoring I . w/c statement of the father indicates further instruction – “ I will hold on to the bar bet his legs to help move him” . it would be necessary for the nurse to intervene if – the pt feet are pressed against the foot board.to decrease muscle spasm. Headache (+) pain. TX available s/s Symptomatic/ Supportive – meaning.  w/c of the ff can possibly indicate the presence of abnormality in an adolescent – uneven hemline – scoliosis. OUTSTANDING S/S BUTTERFLY RASH (also present in pt in PROCAINAMIDE TOXICITY)  the priority nsg care for the pt w/ bucks extension traction shld be – ensure that the traction applied to the affected leg is always attached to the weight. 132 BURNS Traumatic injury to the skin brought about by : FIRE CHEMICALS PROLONGED EXPOSURE TO SUN ELECTRICAL CURRENT HOT H2O CLASSSIFICATION: According to Damage  PARTIAL THICKNESS – FIRST DEGREE 2ND DEGREE  EPIDERMIS DERMIS  Pain  Redness  Eg sunburn  FULL THICKNESS THIRD DEGREE 4TH DEGREE SUB Q MUSCLES MUSCLES & BONES LEATHERY APPEARANCE CHARRED APPEARANCE NO Pain   Pain Burn – triage : face and perineum (priority) Redness Blister Formation pain SUB Q FATS  FATS  INTEGUMENTARY SYSTEM EPIDERMIS & PART OF MODERATE PARTIAL TICKNESS 15-25% MINOR MAJOR less than 15% 25% No . INFECTION Pt Preparation : Bed Craddle Avoid wooded area – “have you Vaccination Use long sleeve Remove ticks w/ twizers – upward straight motion Meds Chloramphenicol Tetracycline . Vit C) Complication FIRST 24HRS – SHOCK 72Hrs .133 FULL THICKNESS >10% NONE <10% LYME’S DISEASE Mountain Fever Rocky RULE OF 9 – CHECK NOTE day 9 page115 caused by BORRELIA BURGDORFERI (deer Dermacentor/ Variabilis – dog ticks ticks) BURN TRIAGE Priority : Burns of THINK: FACE PERIMEUM UPPER & LOWER EXT Burn related to Child Abuse Chemical – Fire R escue A larm C onfine the Fire E xtinguish the Fire 3-30 days or Dermacentor Andersori (wood) 2-3 wks s/s : Fever. Pain.which can lead to paralysis TX been to the woods?” PI DIET DAT (High CHON. Musculoskeletal and CNS . Rashes RASHES: Bull’s Eye Rash or Rounder Rings Generalized rashes At moist body parts PRINCIPLES OF NSG CARE FOR BURN PTS:      B – reathing – Airway U – rine output monitoring R – esuscitation of Fluids N – utrition S – ilvadene Ointment Complications Cardio. Chills. Ca. 134 Causative Agent Herpez Virus Rubella Virus DERMATITIS INC PERIODUnknown 14 -21 days DIAPER (contact) ATOPIC ECZEMA (adult) Peak : During infancy – 9-12 mos Cause : Hereditary Due to prolonged exposure to urine. soap & excreta Prone to asthmatic patients Measle Virus 10 -20 days s/s FEVER and RASH RASH Non Pruritic Begins w/ face & downwards Face & downwards Rose pink – begins w/ trunk Progressing outward S/S : RASH RASH + scaling. Crusting With KOPLICK’S Pruritus or itching SPOTS + same 3 C’s : Coryza Cough Conjuctivitis Viscicles Management: Hydrate the skin w/ cold compress MANAGEMENT: (to all types) Bed rest Antibiotics Antipyretic Meds: Benadryl (antihistamine) ROSEOLA RUBELLA RUBEOLA Exanthem GERMAN MEASLES MEASLES SYPHYLLIS HERPEZ C Agent T Pallidum Zoster GONORRHEA N Gonorrhea Simplex . 135 I. Period 10-13 wks Vericella Zoster Virus 2-7 days Herpes Simplex Viruz TRICHOMONIASIS MONILIASIS/CANDIDIASIS Abdominal Oral Herpez Genital H Caused by TRICHOMONAS Vaginalis Albicans Both are STDs 2-12 days vesicle Charac of discharge : Greenish/ Yellowish WHITISH-CHEESELIKE discharge With FOUL ODOR Steroids Around the mouth Inner thigh Inc Period 4 – 20 days 2 – 5 days Buttocks Genitals Druf pf Choice Amphotericin Flagyl Acyclovir Cervical Ca – complication of Herpez Annual pap smear TIPS  A nurse admits 8yo brought by her mother. Upon assessment, the nurse finds rounded rings of rash. This is indicative of – lyme’s dses;  During the immediate 24hrs pot burn, w/c of the ff is the priority – administration of fluis; 136  A pt tells the nurse that he notice small blisters on his private parts. This is indicative of – HERPEZ  A pt with CA of the cervix was admitted with the ff data: w/c one indicates a possible risk factor – previous tx for herpes;  w/c of the ff indicates effective tx of gonorrhea – (-) purulent discharge;  a pt is diagnosed w/ herpes zoster, w/c of the ff is the priority nsg dx – PAIN;  w/c of the ff is indicative of CHLAMYDIASIS – burning on urination RF Laryngeal or Oral CA Smoking : Lung, Bladder and RACE Jewish – Breast Blacks - Cervix and : Prostrate Whites – Testes PARITY breast having baby after 35 yo : Nulliparity – Multiparity – cervix DIET : High Fat and Low Fiber – CA of Colon Spicy – Ca of Prostrate Raw – Ca of Stomach LABDATA Screening Exams Male: a. Testicular Self Exam – mothly – begins age 16 yo- target are high school Female: a. Pap smear – at age of 18 (if sexually active) - anually b. Breast self exam – beginning age 20 – monthly c. Mamography – baseline : 35-40 yo : AFTER 40 yo – once every 2years After age 50 – annually CANCER Cause Unknown Theory of USE Overuse, Underuse, and Abuse BOTH MALE AND FEMALE  Digital Rectal Exam ANUALLY 40 and above – 137  Sigmoidoscopy age 50yo  STOOL FOR OCCULT BLD Nsg Dx Knowledge deficit ANUALLY after TESTICULAR testes or lump (N – smooth unequal) crytorchidism, spongy Annually after age 50 yo Initial : If pt is TERMINALLY ILL : TIPS FOR CANCER HOPELESSNESS If pt has some wishes or Unfulfilled needS : Powerlessness  w/c nsg dx is a priority for a pt undergoing chemotherapy – SOCIAL ISOLATION;  when undergoing chemotheraphy, w/c solution is used for mouth care – HYDROGEN PEROXIDE; Nsg Care Principles : C hemotherapy – target cells : those rapidly dividing cells; A sess Body Image N tuition/diet : high CHON, well balance C aution pt on s/s E xercise R est  w/c of the ff is an appropriate diet for pt undergoing chemo – bland diet;  the most common sign of Breast Ca is in – upper outer quadrant;  pt w/ CA of esophagus will manifest – DYSPHAGIA COMMON S/S LARYNX VOICE or Hoarseness LUNGS cough or smoker’s cough (productive) STOMACH BREAST discharge OVARIAN fullness or indigestion CERVICAL PROSTRATE phosphatase, nocturia COLON bowel habits Hodgkin’s Dses enlargement of lymph nodes change in changing dyspepsia a lump or a complains feeling of “bleeding” elevated acid change in painless TIPS FOR PSYCHE  A pt w/ chronic depression is to undergo ECT, the purpose is to – relieve the symptoms of depression;  A nurse shld assess the pt w/ ALZEIMER’S DSES for possible change in – orientation;  A pt w/ bipolar episodes is ready for discharge when – she can comply with units activities;  which of the ff is related to trauma – ABRUPTIO PLACENTA.  the initial care plan for a pt with Anorexia Nervosa would require the pt to – remain in public place 1 hour after meals.  in a 3yo child – w/c of the ff shld the nurse assess during admission – special words used for objects and routines.  the appropriate room mate for an 8yo girl w/ leukemia is – 6 yo with hemophilia.138  The nurse would suspect that the child is a victim of abuse if he – keeps quiet while an IV is inserted.  6wks pregnant woman ask the nurse about the signs of pregnancy – w/c one is expected at this time – frequent urination. TIPS FOR OB-GYNE  A Mother Is Crying Besides her baby.  A nurse is caring for a woman in first stage of labor.  w/c of the ff situations reflects an increase in selfesteem of an abuse child . she said “I feel so sorry I couldn’t hold her” – let her stroke the baby.when he ask the nurse for a plastic cup to drink.  the nurse notes mirror image in the fetal monitor – this could be related to FETAL HEAD COMPRESSION. she is timing the duration of contraction – she is correct when she times it from the beginning of one contraction to the end of same contraction  where shld the nurse put the pt on early alcoholic withdrawal – well-lighted room near nurses station TIPS PEDIA  w/c of the ff is expected by 6mos of age – sits w/ minimal support.  w/c of the ff is appropriate way of administering preop meds to 4 yo child – ask the child where she would like the injecvtion to be given .  the most appropriate toy for 18 mos old child – carriage w/ a doll. 139 . 140 . 141 . 142 . 143 . 144 Paralysis of Lower .