Professional Documents
Culture Documents
STEPS IN PASSING
Olive = butter
PROCESS OF ELIMINATION
SAFETY PRINCIPLE
2. TODDLER – falls
3. SUPRATENTORIAL craniotomy – semi fowler’s position
INFRATENTORIAL – flat in bed
PSYCHE PATIENTS
Nsg ALERT:
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.
3. TRACHEOSTOMY TUBE
- to maintain patent airway for pt w/ neurological problems and
musculoskeletal disorders.
nursing care:
1. Suctioning – 10-15seconds
- if (+) bradycardia, STOP
- if accidentally dislodge, insert obturator to keep it open
3. In changing ties – insert new one first BEFORE REMOVING old tie.
5. PENROSE DRAIN
- wound drainage system
- doctors the one who removes this.
- remove gradually
Types:
Levine Tube – for stomach
- 1 lumen, for lavage (cleaning) and gavage (feeding)
8. T TUBE
- to drain excess bile until hearing occurs
- place drainage bag at the level of t-tube
(obstruction of t-tube – there will be excess drainage)
9. HEMOVAC
JACKSON-PRATTS (JP)
WHEN TO EMPTY: when its usually 1/3 to ½ full then RECORD the amount.
THERAPEUTIC DIET
GENERAL CONSIDERATION
PEDIATRIC pt
– by 4-6 mos – START iron supplement due to iron depletion and (-)
extrusion reflex.
- cereals, fruits, vegetables,meat and table foods
- egg yolk (6mos), egg white (1yr)
TRANSCULTURAL CONSIDERATION
JEWS – “kosher diet” (no meat and diary products at the same time)
MORMONS
– words of wisdom (no caffeine, alcohol and once a month fasting)
– the amount due for food is donated to the church
Low Na Diet : AVOID processed foods, milk products and salty foods
CLEAR LIQUID DIET (light can pass thru it, meaning TRANSPARENT)
RENAL DIET
SOFT DIET
NA RESTRICTED DIET
BLAND DIET
GLUTEN-FREE DIET
PHENYLALANINE DIET
- opaque
- transitional diet from liquid
- ex : cream soup, ice cream, milk, leche flan, pumpkin cake
Ph – 7.35 – 7.45
PCO2 - 35 – 35
HCO3 - 22 – 26 meq/L
Ph Compensatory Mechanism
PRIORITIZING of case:
Med.-Surg – “abc”
Psyche - safety first
Fire - race
Triage - pt evaluation system (prioritizing)
APGAR SCORING
0 1 2
T.R.I.A.G.E -prioritizing
LEVEL 1 “emergency”
severe shock, cardiac arrest, cervical spine injury, airway compromise, altered
level of consciousness, multiple system trauma, eclampsia
LEVEL 3
TIPS ON PRIORITIZING
DELEGATION
CONCEPT OF DELEGATION
AMPUTATION
complication: hemorrhage (keep tourniquet @ bedside)
1st 24hr – goal: to decrease edema – elevate the stump at foot part w/
the use of pillow
APPENDICITIS
BURNS
Complication: infection
CAST, EXTREMITY
Nsg care:
Types:
FLAIL CHEST
GASTRIC RESECTION
HIATAL HERNIA
HIP PROSTHESIS
LAMINECTOMY
LIVER BIOPSY
LOBECTOMY
MASTECTOMY
-removal of breast
-elevate or extend affected arm to prevent lymp edema (or elevate higher
that the level of the heart.
AVOID: venipuncture, specimen taking, blood pressure – ON THE AFFECTED
ARM coz there is no more lymph node w/c predispose pt to bleeding.
Due to removal of axillary lymph node, avoid also gardening and hand sewing
PNEUMONECTOMY
RESPIRATORY DISTRESS
Pedia : TRIPOD – lean forward and stick out tongue to maximize the
Airflow
RETINAL DETACHMENT
- to prevent further detachment, place pt on the AFFECTED SIDE.
VEIN STRIPPING
- keep extremities extended then elevate the legs at level of the heart to
promote venous return
TIPS
liver biopsy is done on a pt. – during 1st 24hrs after the procedure, turn the pt
on his abdomen w/ pillow under the subcoastal area;
when draining the L lower lobe of the lung – the pt shld be positioned on his R
side w/ hip higher or slightly higher than the head;
THERAPEUTIC COMMUNICATION
In GROUP DISCUSSION – nurse is just a facilitator – let the group decide, he/she channel are
concern back to the group.
THERAPEUTIC PHRASES
– it seems… you seem….
- open ended question
- close ended – for manic pt and pt in crisis
- direct question- for suicidal pt
ISOLATION PRECAUTION
STRICT
(airborne dses, direct contact-Diptheria)
TB OPTIONAL OPTIONAL
(negative airflow room)
CONTACT
(direct contact – NOT AIRBORNE DSES)
eX SCABIES
UNIVERSAL X
(AIDS, HEPA b – TRANSMITTED
BY BLD AND DODY FLUIDS)
TIPS:
When implementing universal precaution, w/c nsg action require intervention:
recapping the needle – this might prick your hand;
When discarding the contents of the bed pan use by a pt under enteric precaution
– GLOVE IS NECESSARY;
A nurse is giving health teaching to the parents of child with scabies: family
member must be treated;
Patient with full blown AIDS is placed on isolation precaution – pt ask nurse why his
visitors is wearing mask – response: it will help in the prevention of
infection;
Essential when a pt w/ meningitis is kept in isolation: isolation precaution
remains until 24hrs after initiating antibiotic therapy
DIAGNOSTIC PROCEDURES
side notes:
GENERAL CONSIDERATION
TRANSCULTURAL CONSIDERATION
Obtain help of interpreter when explaining procedures – (except or don’t ask family
members)
For muslim patient - they prefer same sex health care provider however, if
procedures require life threatening – they prefer to have
male doctor.
NON STRESS TEST (NST) – correlates fetal heart rate w/ fetal movement
a. ring a bell
b. feed the patient
then check FHR, NST is (+) if FHR increase at least 15 beats/min than the baseline. (ex. 140 FHB
baseline, then after challenge it increase to 155)
POSITIVE result means, BABY is REACTIVE (good condition) and no need for contraction stress
test/oxytocin challenge test – coz baby is OK and doing well.
types of deceleration
a. early deceleration – indicates head compression (MIRROR IMAGE)
c. variable deceleration – due to cord (image: U or W shape) and slowing of FHR can occur
anytime.
If (+) CST, meaning there is deceleration, baby is NOT OK coz there is decrease FHR and
during labor he/she may stand the labor process.
BIOPHYSICAL PROFILE
10 points
score below 6, indicates fetal jeopardy
ULTRASOUND
Done in 1st trimester can be done on the 2nd wk (14-16 wk) Extract blood at umbilical cord
(can be done as early as 5th wk but - but not recommended bec. of danger then it is tested if it really comes
can be done on 8-10th wk) abortion (assess pt age of gestation) from the umbilical cord (can be
done on either 2nd or 3rd tri.
a. infection
b. bleeding
c. abortion
d. fetal death
TIPS
• EARLY DECELERATION – expected in the fetal monitor when there is fetal head
compression;
• A mother asked the nurse what will amniocentesis provide during pregnancy:
it will show as whether the baby lungs are developed enough for the baby to be born;
• a nurse is preparing pt for lower abdl usg – w/c of the following done by the pt
needs further teaching – pt voids b4 the procedure;
CARDIOPNEUMOGRAM
– use to diagnose apnea of infancy
– assess HR, RR, nasal airflow and O2 saturation – N 95-98%
below 85 – report ASAP
GLUTEN CHALLENGE
- detect presence of Celiac Disease (CD) - intolerance to gluten;
- pt is given gluten rich food for 3-4 months the observe s/s of CD
(+) if w/ click sound (lateral) (+) barlow’s click – press downward and w/ click sound
SCOLIOMETER
test for pre-teen : “bend over test” – bend and touch the toe;
Purpose: test for sickle cell anemia Purpose: test for sickle cell anemia
Specimen : Blood : (blood + solution, if (+) TURBID Specimen : Blood : bld + electropoiesis, if sickling of RBC
Therefore TRAIT CARRIER (S or C shape RBC), therefore + for SC Dses
- to detect PKU
(in PKU there is absence of PHENYLALAMINE HYDROXYLASE- PH)
If absent PH, no one will convert PH to Tyroxine, therefore it will accumulates to brain
and can cause mental retardation.
PH came from CHON rich food. At birth, it is usually negative, so give CHON food first for
3wks then retest.
Before test, give chon rich food for 1-4 days before test. (adult)
N PH level - >2mg/dl
(if 4mg/dl – indicative of PKU, 8mg/dl – confirms PKU)
SWEAT CHLORIDE TEST
- to detect Cystic Fibrosis (in CF, the skin becomes impermeable to Na.
meaning cannot reabsorb Na and it accumulates outside of the skin);
- Mother complain that her baby taste salty;
- PILOCARPINE – used in the test to induce sweating;
Types:
a. sweat chloride test – N 10-35 meq/L (above 40 meq/L– (+)
b. serum chloride test – N 90-110 meq/L (above 140 meq/L – (+)
TIPS
pt w/ PKU would more likely to have (+) result in gluten capillary bld test if there is – adequate
CHON in the diet;
mother complains that her baby taste salty – which test is to be performed : sweat chloride
test;
9 yo pt has (+) result for sweat test – this indicates possible dx of Cystic Fibrosis;
DIAGNOSTIC PROCEDURES
I. CARDIOVASCULAR
ABNORMALITIES
a. atrial fibrillation – p waves “halos magkadikit.
(no discernable p waves)
B. CARDIAC CATHETERIZATION
nsg mgt :
monitor distal pulses (if brachial site: check @ radial
if femoral site : check @ dorsalis pedis)
if weak or no pulse – REPORT
if (+) bleeding – report (“sandbag 10-20 lbs” – shld be at bedside)
C. STRESS TEST
D. CORONARY ARTERIOGRAPHY
E. SWAN-GANZ CATHETERIZATION
F. BLOOD CHEMISTRIES
Hyperthyroidism – inc CA
Renal Calculi Formation – inc CA @ bld
GLUCOSE (80-120)
- Higher than 140 – hyperglycemia (acidosis – may lead to ineffective breathing pattern
and airway is the main problem)
Creatinine (.5-1.5)
LDH inc for MI for 3-4 days then it returns to N after 10-14 days
CPK or CK
G. HEMATOLOGIC STUDIES
PLATELET (150,000-450,000)
- spontaneous bleeding occurs when platelet dec
(pt also prone to injury)
PT PTT APTT
(11-12 sec) (60-70 sec) (30-40 sec)
HCT - 35-45%
- determine the adequacy of hydration and the ration of plasma to
the cellular component blood
DOPPLER USG
- to detect the patency of bld vessels – arteries & veins esp of lower
extremities;
- painless, non invasive, NO SMOKING 30 min-1hr b4 the test
PULSE OXIMETRY
- determines the O2 saturation at blood
- N 95-98 – attach to finger or earlobe (do not expose e light)
II. RESPIRATORY
BRONCHOSCOPY
CHEST X-RAY
SPUTUM STUDIES
- to determine the gross characteristic of the sputum (refers
to the amount, color, abnormal particles, consistency and
characteristic)
TYPE OF SPUTUM
BRONCHITIS - gelatinous
THORACENTESIS
- aspiration of fld at thoracic cavity
(for diagnostic & therapeutic purpose)
Nsg alert:
LUNG SCAN
MANTOUX TEST
5mm in duration – (+) for HIV, multiple sex, previously (+) pt;
10mm - (+) for immigrants, children below 3yo and for
pt w/ medical condition – DM & Alcoholism
15mm - (+) for general population
LUNG BIOPSY
III. NERVOUS
EEG
nursing alert:
Use radiation to determine use electromagnetic field use gamma rays or positron electron
tissue density to detect abnormality of tissue density to detect abnormality of tissue density;
(detect cancer and tumor) also to detect O2 saturation @ tissue;
physiology of psychosis; and to evaluate tx like CA Tx
CONTRAINDICATION CONTRAINDICATION
(same w/ ct scan BUT w/ addtl)
a. pregnancy;
b. obese pt (more than 300 lbs); NO METAL OBJECTS
c. claustrophobia (give anti-anxiety b4) - jewelries, insulin pump,
d. pt w/ unstable v/s (arrhythmic & HPN); pacemaker, hip replacement
e. pt w/ allergy to dye
“clicking sound” will be heard & lie still during the procedure lie still
lie still during the procedure and “thumping sound” will be heard
CEREBRAL ANGIOGRAM
CONTRAINDICATED IN:
Nursing Alert:
a. keep pt NPO;
b. assess pt for allergy;
c. monitor for signs of bldg;
d. inc oral fld intake to excrete dye;
e. keep epinephrine and or benadryl at bedside for emergency
LUMBAR PUNCTURE
position:
CSF ANALYSIS
Ear licking w/ fluid – test if (+) glucose bec. CSF has glucose.
MYELOGRAM
ALERT:
Rationale for both oil and water based dye is TO PREVENT the upward dispersal of dye
w/c can cause electrical meningitis (s/s includes: (+) seizure, headache)
IV. EENT
• TONOMETRY
• GONIOSCOPY
feces : “chalky-white”
GUAIAC TEST
AVOID the following 3 days B4 the test – bec it can yield to FALSE (+)
RESULT : Red Meat, Fish and Horse Radish
CHOLANGIOGRAPHY
- visualization of biliary tree (includes, hepatic duct & common bile duct) – same with
CHOLECYSTOGRAPY – but medium given orally;
GASTRIC ANALYSIS
ULTRASONOGRAPHY
LIVER BIOPSY
- aspiration of sample tissue from the liver to detect: Hepatic CA and Cirrhosis;
COLONOSCOPY
- (+) Consent
- NPO b4
- clear liquid diet – 2days b4 the procedure
VI. ENDOCRINE
Specimen: 24 hr urine
epinephrine norepinephrine
AVOID: vanilla containing food 3 days b4 test – ice cream, coffee, chocolates
RAIU
-pt is given iodine 131 then after 24hr followed by a thyroid scan
-inc indicates hyperthyroidism, dec hypothyroidism
-AVOID: iodine rich-food (sea foods, sea shells, sea weeds) 7-10 days b4 and to include
other diagnostic procedures that uses contrast medium (“NO” - angiogram
test). – bec it may yield to false (-) result.
SULKOWITCH’S TEST
VII. R E NA L
URINALYSIS
- to detect infection
- prepare storage container
KUB IVP
- xray of the kidneys, ureter and bladder - xray of the kidneys, ureter and bladder
- NO SPECIAL PREPARATION NEEDED - uses contrast medium/ dye
- assess for allergy, then inc. oral fld intake after
- benadryl or epinephrine at bedside for allergic rxn
- NPO POST MIDNOC, cleansing enema in AM
CYSTOSCOPY
RENAL BIOPSY
CYSTOURETROGRAM
CYSTOMETROGRAM
VIII. MUSCULO-SKELETAL
ELECTROMYOGRAPHY
ARTHROCENTESIS
- visualization of joints
- KEEP TORNIQUET, ICE PACK and ANALGESIC at bedside
BONE SCAN
IX. MISCELLANEOUS
SCHILLING’S TEST
eg. If 100mg Vit b was taken – 60mg shld retain at stomach and
40mg will be excreted.
URINE UROBILINOGEN
BENCE-JONES PROTEIN
ROMBERG’S TEST
if lifespan of RBC >120 days, therefore HEMOLYTIC ANEMIA (EX. SICKLE CELL)
Treatment: tetracycline
Pt is scheduled for liver biopsy. What shld the nurse instruct pt to do during needle insertion? -
hold breath during the procedure upon insertion of the needle.
Staff nurse is observing a nurse caring for pt w/ cvp. W/c action of the nurse require intervention? –
touching the edge of the soiled dressing using clean gloves.
Pt undergoing ERCP – important prep for nurse to make would be: keep pt NPO b4 the
procedure.
Pt w/ coronary angiogram, the catheter was inserted at the L femoral artery. w/c intervention is
appropriate after the procedure: palpate the popliteal and pedal pulses.
In explaining to the pt about cystoscopy the nurse shld say : the bladder lining will be visualize.
A mantoux test is (+) – if the nurse assesses w/c of the following: in duration.
w/c of the ff will yield an accurate reading of CVP: when the zero level of the manometer is at
the level of R atrium.
w/c responses made by the pt indicates that he understands the procedure to be done in a CT scan:
“a dye will be injected to me”.
A pt is to have an upper GI series – which statement shows that he understood the instruction given
: “I will drink the dye”.
MRI is the primary diagnostic tool for multiple scelosis bec it promotes visualization of plaques
at the brain.
DAY 5 (8 Feb 2005)
PHARMACOLOGY
I. GENERAL CONSIDERATIONS
ASIANS – are stoicism attitude (they refuse meds if for the 1st time)
MIDDLE EASTERNERS - they expect meds during first contact w/ hx care provider
JEHOVAH’S WITNESS – do -
ECHINECEA
- use to boost the immune system;
- for pt. with cancer
ST JOHN’S WORT
- anti-depressant (it funx like MAO inhibitor);
- do not give to pt taking MAO
VALERIAN
- sedative (used also as anti-anxiety agent)
- adverse effects – GI Irritation
GINGCO BILOBA
- blood thinner;
- use to enhance bld circulation;
- for pt w/ alzeimers
- CONTRAINDICATED to pt with bleeding disorders
Document all medical admin record: time, route, dosage and untoward reaction;
I. ANTIPSYCHOTIC
- major tranquilizer;
- for SCHIZOPHRENIA (pt has EXCESS DOPAMINE);
- plays as treatment to the symptoms NOT CURE to schizo – meaning it modify
the symptoms (target symptom: to decrease dopamine)
ex.
Haldol
Chlorpromazine
Clozapine (chlozaril)
Olanzapine (zyprexa)
Risperdon
CLIENT TEACHINGS:
DYSTONIA
ex. L-Dopa
Levodopa
Levodopa-Carbidopa
Health Teachings:
IB. ANTICHOLINERGIC
- decrease ACETYLCHOLINE
ex. Benadry
Cogentin
Health Teachings:
II. ANTI-ANXIETY
- minor tranquilizer
- decrease Reticular Activity System – center of wakefulness
HEALTH TEACHINGS:
a. report ADVERSE EFFECT:
PARADOXICAL REACTION – opposite of side effects
b. Danger of Dependency
c. AVOID:
Caffeine, Alcohol – it increase the depressant effect of the drug
d. check RR – it causes respiratory depression
e. administer VALIUM separately – because it is incompatible with any drug –
use different syringe.
III. ANTI-DEPRESSANT/MANIC
a. TRICYCLICS
b. MAO
c. STIMULANTS
d. SSRI
Hx Teachings:
Hx Teachings:
C. STIMULANTS
(Ritalin, Dexedrine and Cylert)
Hx Teachings:
s/e: GI
III.1 ANTIMANIC
Lithium (lithane, lithobid, escalith)
Tegretol
Depakine/ Depakote
A. LITHIUM
- it alters level of neurotransmitters
Hx Teachings:
diet:
High Na (6-10 gms) and High Fluid (3-4L)
N Na – 3 gms, N fluid intake 3L
Basically, Lithium is a salt
Report also:
Hx Teachings:
Lithium is effective with 10 – 14 DAYS before it will reach its therapeutic level.
CONTRAINDICATION OF LITHIUM:
• Pregnancy;
• Lactating;
• Kidney disorder
- if above s/s are (+) to patient, instead of lithium use TEGRETOL, DOPAKINE/ DEPAKOTE
NSG ALERT:
• Report GINGIVITIS;
• Report S/S of Bone Marrow Depression – pancytopenia
(dec RBC & WBC);
• Instruct pt to use SOFT BRISTTLED TOOTHBRUSH;
• Instruct pt to MASSAGE GUMS and frequent oral hygiene
CHOLINESTERASE INHIBITORS
For MYASTHENIA GRAVIS : Prostigmin (long acting) and Tensillon (short acting)
TENSILLON – short acting – only for 5 mins. – it increase muscle strength in 30 seconds
(therefore, if muscle weakness disappear within 30 seconds – it is MYASTHENIA GRAVIS)
Drug Action:
• Increase muscle strength (ex. Increase chewing ability or able to chew food forcefully)
• GIVE B4 MEALS or any activity;
• Meds is FOR LIFE;
• Report s/s of HEPATOXICITY – RUQ pain of abdomen and JAUNDICE
ANTICOAGULANT
HEPARIN: AVOID – green leafy vegetables – bec it is rich in Vit K and will counteract the effect of anti coagulant.
NSG ALERT: monitor PTT (N 60-70 SEC, TIL INR of 175), if more than INR - HOLD
“INR” – refers to the upper limit of meds from N value to the maximum dose
COAGULATION PROCESS:
thromboplastin
Vitamin K dependent clotting factors PRO THROMBIN THROMBIN
COUMADIN FIBRINOGEN
HEPARIN
FIBRIN (CLOT)
ANTIARRYTHIMICS
Side notes:
Health teachings:
Ventricular arrythmia
CARDIAC GLYCOSIDES
- increase force of contraction;
- affects the automaticity and excitability of the heart muscle;
- K – shld be monitored when in this meds therapy
(The heart contraction is regulated by Na and K pump. If K decreases, Calcium enters and it will result to a
more increase force of contraction due to Na and Ca pump conversion.)
DIGOXIN DIGITOXIN
CLIENT TEACHINGS:
EXCRETION
Digoxin – kidney – monitor renal funx test (BUN & Crea) – report if inc;
Digitoxin – liver – AST/ ALT
THERAPEUTIC LEVEL:
a. Digoxin : .5 – 2 ug/L
b. Digitoxin : 14 – 26 ug/L
NITRATES (nitroglycerine)
Decrease in Preload – decrease in the amount of blood that goes to the LV;
AFTERLOAD – amount of resistance offered by blood vessels that heart shld overcome
when pumping blood
Theophylline - N 10-20;
- for ACUTE ATTACK and PREVENTION of ASTMA
EXPECTORANT (robitussin)
ANTIBIOTICS
- bactericidal;
- effective: (-) infection;
- give ON EMPTY STOMACH – B4 MEALS;
- Hx teachings: REPORT rash, urticaria and “STRIDOR” – indicates
airway obstruction;
- side effects: NAVDA + GI Irritation
Health Teachings:
a. Report sore throat, fever, chills, body malaise because meds
cause AGRANULOCUYTOSIS;
b. Report lethargy, bradycardia, and INCREASE SLEEP – indicates
that pt is having HYPERTHYROIDISM;
c. Diarrhea with metallic taste – sign of IODINE TOXICITY
ANTIDIABETICS (INSULIN)
dizziness/ drowsiness
difficulty in problem solving
decrease level of consciouness
cold clammy skin
INJECT AIR FIRST to NPH then inject air and WITHDRAW FIRST with REGULAR.
SULFONYLUREAS (Orinase)
- for DM type 2;
- stimulate pancreas to produce insulin;
- effective – N bld sugar level;
- give b4 meals regularly;
- teachings:
a. s/s of hypoglycemia;
b. monitor renal funx test;
c. antidote for hypoglycemia – ORANGE JUICE
DIURETICS
Target Organs
a. Diamox – exerts effect at Proximal Convuluted Tubules;
b. Lasix – at Loop of Henle;
c. Diuril – at Distant Con. Tubules
THIAZIDE (diuril)
- give in AM;
- monitor for hypokalemia;
- check I & O, K level, PR and BP
ANTIGOUT
PROBENECID COLCHICINE ALLOPURINOL
TEACHINGS:
MYDRIATRIC (AK-Dilate)
OXYTOXIC
PITOCIN METHERGIN
Patient receiving DIAZEPAM, the nurse notice that there is no change in patient
behavior. What shld the nurse do? – VERIFY THE PT DIET
Pt w/ DIVERTICULITIS (pt has diarrhea) – the ff meds were given: what meds the nurse
shld question : LACTULOSE
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 to receive NPH at 7:30am, the nurse shld expect for hypoglycemia – LATE in the
AFTERNOON
TYPES OF PRECAUTION
P H GL GW M
AIDS (universal) x yes yes yes yes
P – private room
H – handwashing
GL - gloves
GW – gown
M - mask
AIDS – universal
Norwalk Virus – respiratory
Hepa A – contact
MRSA – contact
Scabies – contact
Day 6 (Feb 9, 05)
D.I.S.E.A.S.E.S
(MEDICAL-SURGICAL NURSING)
GENERAL CONSIDERATION
• Priority: Oxygenation
• The disorders result as alteration in the function of HEART (pump), BLOOD
(transport mechanism of oxygen, nutrients, hormones & CO2) and BLOOD
VESSELS (passageway).
PEDIATRIC CONSIDERATION
b. there are structures which are present at birth that may alter the route of blood
circulation (present at birth: foramen ovale, ductus arteriosus, ductus venosus)
c. note the CARDIAC RATE of pediatric pt (minimum $ y. children – 90-110, older c. – 70)
HEART SOUNDS:
S1 - normal – “lubb”
S2 - -do- - “dub”
- in assessing S1 & S2 use BELL of steth
TYPES
CARDIOGENIC – pump failure (CHF, MI, Atherosclerosis Heart Dses, Mitral Valve Dses)
HYPOVOLEMIC - related to fluid loss (pt w/ open wound, traumatic injury, burn)
ANAPHYLACTIC - cause by allergic reaction (laB procedure w/ dye, asthma, poison)
NEUROGENIC - caused by vasomotor collapse
(vasomotor – located @ medulla oblongata w/c is responsible for dilatation & constriction of bld vessels)
SEPTIC – due to systemic infection (ex. Septicemia)
a. Altered level of consciousness (dec bld circulation – result to dec o2 in the brain);
b. Hypotension;
c. Tachycardia and Tachypnea
Priority Intervention: Fld replacement (D5Lr, NSS. Bld Trans – for jehova’s use plasma expander)
ANEMIA
MP: Decrease RBC due to decrease production or increase destruction
Risk Factors:
Age
Gender
Surgery
Secondary to existing medical condition (ex. Renal Failure)
Kidney – produce erythropoiten that stimulates bone marrow to produce RBC
TYPES:
S/S : Fatigue
Fainting
Forgetfulness
Pallor, cold clammy skin
Dyspnea (due to dec RBC)
Lab data:
Decrease in HgB (N male: 14-18, Female: 12-16)
Characteristic of RBC: HYPOCHROMIC & MICROCYTIC
Priority Intervention:
b. Diet: iron rich food – (organ meat, dried foods, “egg yolk” – iron, “egg white” – CHON);
c. provide patient with BED REST – due to fatigue
PERNICIOUS ANEMIA
- common in elderly;
- common in POST GATRIC SURGERY
In elderly, there is that GASTRIC ATROPHY w/c leads to dec in the Intrinsic factor
S/S:
3F (fatigue, fainting, forgetfulness)
Beefy Red Tongue or glossitis
Peripheral Neuropathy (tingling sensation at lower extremities – usually both legs are affected)
Lab Data:
a. check Hgb
b. SCHILLING’S TEST (24hr urine)
c. RBC characteristic : MACROCYTIC & HYPERCHROMIC
Priority Intervention:
a. Correct the deficiency – give Vit B12 (IM, Once a month for lifetime);
b. Bed rest – due to fatigue
Nsg Dx:
Activity Intolerance (NO RISK FOR INJURY coz NO P. NEUROPATHY)
- autosomal recessive
- hereditary
- presence of “S or C” shape Hgb due to dec O2 (SICKLING OF RBC)
Risk Factors:
S/S:
3Fs + Fever (due to dehydration) + Pain + Jaundice Hepatomegally
Complications:
b. Spleenic Sequestration Crisis – massive entrapment of red cells in the spleen & liver
c. Aplastic/ Megaloblastic Crisis
– bone marrow depression w/c resulted to DEC RBC, WBC & PLATELET
APLASTIC ANEMIA
THALASEMIA
Risk Factors:
Common in Blacks, Italian, Greeks, Chinese, Indians
MP: Hereditary
Autosomal Dominant – common in female and male
There is a defect in polypeptide
Types:
Lab Data:
HgB
Clotting and Bleeding Time
PI : Bld Transfusion,
IVF
Dietary supplements of Folic Acid and Iron
Surgery (last resort)
LEUKEMIA
MP: proliferation of immature WBC
Types:
TRAID S/S:
Lab Data:
- common in BLACKS;
- cause: idiopathic
unknown (viral and autoimmune)
s/s: petechiae
ecchymosis
hemorrhage
(all signs of bleeding)
HEMOPHILIA
TYPES:
S/S:
Hemarthrosis – bldg between joints that usually affects ankle, knee and elbow joints;
Hematoma
Hematuria
Hematemesis
(above mentioned are signs of HEMORRHAGE)
If all of the ff data were obtained by the nurse, w/c one is MOST SUGGESTIVE of
CARDIOGENIC SHOCK - Inc. HRate from 84 to 122 bpm;
The nurse admitted a 4 yo child with SICKLE CELL DSES – the priority for the
patient is – HYDRATION;
a mother of 15 mos old child with IDA makes the ff comment. w/c one is related to
child condition - “MY CHILD DRINKS 2 QUARTS OF MILK/DAY”;
w/c of the ff is the priority intervention for pt w/ IDA – PROVIDE BED REST
ALTERNATING w/ activities;
CARDIOVASCULAR PEDIATRICS
FETAL CIRCULATION
3 FETAL STRUCTRUES
PLACENTA UMBILICAL VEIN DUCTUS VENUSUS LIVER
(functionally, closes at birth)
Vena Cava
UMBILICAL ARTERIES
AORTA
R Ventricle LA
LV
LUNGS
L VENTRICLE
Therefore, if these 3 fetal structures will not close, CONGENITAL HEART DISEASE
Complication: CH Failure (check for “murmur”) CVA (due to plycythemia – Inc RBC)
PI : Oxygenation
Surgery
If < 2yrs old prepare the patient the moment the diagnosis was confirmed/ determined;
For 2-7 yrs old – surgery is equal to child age ( ex 3yo, therefore prepare the child 3 days prior to surgery)
PI : Oxygenation
INDOMETHACIN
TETRALOGY OF FALLOT
PI : Oxygenation
Position the Pt. : SQUATTING
Surgery
COARCTATION OF AORTA
PI : Oxygenation
Position the patient: Orthopneic or semi – fowler’s position
KAWASAKI’S DISEASE
a child who was brought in to a well baby clinic turns cyanotic while crying –
REFER to the physician;
w/c of the ff data in mother health history indicates a risk factor for congenital
heart disease – ADVANCE AGE;
Risk Factors:
Family History
Atherosclerosis
Smoking
Elevated Cholesterol
HPN
Obesity
Physical Inactivity
Stress
CAD
HYPOXIA ISCHEMIA
NECROSIS
ANGINA
Myocardial Infarction – “ jaw pain”
this leads to decrease O2 – and will result to the conversion of aerobic metabolism to
anerobic thereby resulting to the production of LACTIC ACID – that will stimulate the nerve ending of the
heart w/ will produce/ result to PAIN that is precipitated by:
EATING
Elimination – due to valsalva manuever
Exercise/effort/ exertion
Emotion
Extreme Temperature – “cool temp” – vasoconstriction
sEx
PAIN
• Nsg Dx : PAIN
Altered Tissue Perfusion
Impaired Gas Exchange
• Goal of CARE
HEALTH TEACHINGS:
Post MI Angina
CARDIOVERSION DEFIBRILLATION
- synchronize - unsynchronized
- esp. for VTACH w/ PULSE - for VTACH w/o PULSE
FOR ANGINA APIN – instruct patient to report pain that last more than 2o minutes (indicative of MI);
The HEART will pump harder- Inc HR (tachycardia) – that will result to enlargement
of the heart muscle (hypertrophy) – w/c can lead to dilatation and congestion of the
cardiac muscles - thereby resulting to decrease in the cardiac output.
X-ray X-ray
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.
HEALTH TEACHINGS :
a. Activity – rest
b. dietary counseling – NO PMS
c. report s/s of complications
DIGITALIS – D. Toxicity: yellow vision;
Muscle weakness (hypokalemia) – that can lead to arrythmia
Dyspnea – s/s of pulmonary edema;
120/80, therefore N BP : 110/70 if BP elevated B4 20-24 wks & cont after delivery – CHRONIC
HPN
TYPES:
a. ESSENTIAL HPN – cause – unknown
b. BENIGN – usually of long duration, onset is CHRONIC
c. MALIGNANT – acute or abrupt onset, short in duration
d. SECONDARY – related to existing medical condition
PRE-ECLAMPSIA TYPES:
H – emolysis
E – levated Liver Enzyme
L – ow
P- latelet
(All are signs of bleeding)
S/S of HPN:
Headache
Retinal Hemorrhage
Edema
- above s/s can further lead to complications: Coronary artery dses
CHF
Chronic Renal Failure
CVA
LAB DATA:
Blood Pressure
Elevated Cholesterol
For PIH : (+) Proteinuria, Inc BP and Inc Cholesterol
Nsg Dx:
Altered Health Maintenance
Risk for Injury
PIORITY: Stabilize BP
How?
I. Non-Pharmacologic Features
Stress Management
Deep breathing
Diet : Low Na/ Cholesterol
Position : if inc BP – supine position
Antihypertensive
Diuretics
Aspirin
Antilipimic - simvastatin & lovastatin – give after meal nighttime
Monitor liver Funx test – meds above are hepatotoxic
Pts w/ PIH meds:
a. MgSo4 – antidote is CAgluconate
b. Darkened room – to dec stimulus thereby preventing convulsion
TYPES:
LAB DATA : Inc WBC & ESR DOPPLER USG Inc Cholesterol and Ca
Anticoagulants
Vasodilators (papaverin – pavabid)
Antihypertensive
Lab data:
1. conservative test – TRENDELENBURG TEST – pt lie down, elevate/ raise the legs then
stand up and observe for bulging of vein;
2. DOPPLER USG
Nsg Dx : PAIN
Altered Tissue Perfusion
Hx Teachings :
TYPES:
S/S:
• In utilizing mind over body principle for pt w/ HPN – w/c intervention is appropriate
- relaxation and stress mgt;
• Ff MI, when shall I resume sexual activity? – when you can climb 2 plights of
stairs w/o shortness of breath then sexual activity is safe;
• Apt w/ CHF who is taking diuretics exhibits the ff, w/c requires further investigation
(not expected to pt) – wt gain of 3 lbs in 2 days;
• In addition to assessing a pt w/ Burger’s Dses, w/c of the ff data supports the Dx. –
smoking;
RESPIRATORY
General Consideration:
Key Points for Assessment - note for abnormalities in RATE, RHYTHM & DEPTH
Common CHARACTERISTIC in Breathing
At birth, the child can maintain temperature by burning brown fat – and increase burning – bi products
is Increase fatty acids that will cause acidosis – that can worsen the Resp. Distress Syndrome – a
group of symptoms (mgt: maintain temperature).
HYPOVENTILATION
HYPERVENTILATION
ALKALOSIS
Cause : lack of CO2 – the pt will decrease rate of breathing to save CO2.
co2 then combine with H2O to form carbonic acid – if inc, can
lead to acidosis – and the brain will compensate by
hyperventilating – and increase elimination of CO2 will cause
ALKALOSIS.
Cardioneumogram – measures O2
Polysonography
ABG Analysis
Tx :
PI : AIRWAY
Intervention :
Bronchodilators – theophylline
Rest
Oxygen – low flow (1-2 l/min) – higher than this will result to decrease in the stimulus for breathing –
w/c is CO2
Nebulization
Chest Physiotherapy – b4 meals or at bed time
High Fowlers
Intermittent Positive Pressure Breathing
Aerosol
Liberal Fluid Intake
Meds : Aminophylline
Steroids
Theophylline
Histamine Antagonist
Mucolytic
Antibiotics
Hx Teachings :
Appropriate rest;
Activity – avoid those that will expose pt to allergens;
AVOID PROPANOLOL and ASPIRIN – causes BRONCHOSPASM;
Exercise – “blowing exercises” – bubbles, trumpet
CYSTIC FIBROSIS
Respiratory GI
Hereditary Autosomal Recessive
S/S : MECONIUM ILEUS – within the 1st 24-36 hrs – if baby fail to defecate – suspect for CF;
ABDL DISTENTION
Malabsorption Syndrome – STEATORRHEA – foul-smelling stool w/ Inc Fats & Bulky
Salty to Kiss – bec skin becomes impermeable to Na
Common Complications: because of thick mucus plug
Lab Data : Sweat Chloride Test – N (if sweat) 10 – 35 mg/dl – INCREASE IF (+) CF
(if serum) 90 – 110 mg/dl - -do-
CROUP DISORDER
common in TODDLER INFANTS & TODDLER INFANTS usually (less than 6 mos)
Nsg care:
Hx Teachings :
SYRUP OF IPECAC – for Croup – it induces vomiting- bec it will stop the spam thereby preventing
further coughing.
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
PI :
AIRWAY 1-2 L/min;
Meds: Bronchodilator – Atrovent
Exercise: Blowing;
Rest periods in between activities
PNEUMOTHORAX
MP : partial or total collapse of lungs due to:
Types :
PI : Chest Tube Drainage System – restores the (-) pressure within the thoracic cavity
PNEUMONIA (PNA)
PI :
• Airway – O2
• Position : Semi-fowler’s or Orthopneic
• Bed Rest
• Inc Oral fluid intake
• Antibiotics
• TCDB (turning, coughing, & deep breathing)
TB HISTOPLASMOSIS MYCOBACTERIUM
AVIUM COMPLEX
Risk Factors:
ASIAN IMMIGRANT
IMMUNOSUPPRESSION
MALNUTRITION
a. initially asymptomatic;
b. low grade fever that occurs in the afternoon;
c. body malaise or weakness;
d. coughing w/ bld streaked sputum;
e. weight loss
Mantoux Test
Xray – confirmatory test
Sputum - @ least 2 (-) to be effective
Nsg Dx :
Infection;
Ineffective Breathing Pattern
• PROPHYLACTIVE TREATMENT OF TB – INH for TWO WKS (take Vit B6 to avoid NEUROPATHY)
Rifampicin
INH
Streptomycin
Ethambutol
- take above meds for 6-12 moths to avoid resistance
you observed a nurse caring for a child in a CROUPETTE, if you are the nurse in-
charge, what would be your #1 PRIORITY? – changing the linens & clothings to
keep child always dry;
which data in the past medical history of the pt. supports a dx of cystic fibrosis –
MECOMIUM ILEUS in the neonate;
w/c of the ff intervention being carried out by LPN would require immediate
intervention – suctioning the pt for 20 seconds;
a client w/ TB will experience - low grade fever;
a 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
ENDOCRINE
General Consideration
Reportable S/S :
skin changes – “have you noticed any change in your skin color”
(“bronze skin pigmentation – addison’s dses)
Inc. temperature
S/S of Shock
PKU
- AUTOSOMAL RECESSIVE PATTERN of transmission (inherited)
MP :
There is Absence of Phenylalamine Hydroxylase (the one that converts
Phenylalamine to Thyroxine ( a precursor to Melanin).
S/S :
Initially – asymptomatic
For OLDER CHILDREN : Diarrhea
Anorexis
Lethargy
Anemia
Skin Rashes and seizure
Musty odor of urine (due to phenyl pyruvic acid)
Since (-) melanine: hair : blonde
Eyes: blue
Fair Skin
Lab Data :
GUTHRIE CAPILLARY BLD TEST – initial screening – done after the infant has ingested CHON
for a minimum of of 24 hrs.
Secondary screening : done when the infant is about 6wks old – test fresh urine w/
PHENISTIX – WHICH CHANGE COLOR
Nsg Dx :
Knowledge Deficit
Altered Thought Process
Risk For Injury
Hx Teachings :
Untreated PKU can result in failure to thrive, vomiting and eczema – and by about 6 mos,
signs of brain involvement appear.
LYMPHOCYTIC THYROIDITIS or
JUVENILE HYPOTHYROIDISM
Cause : Autoimmune or genetics
MP : Decrease in T3 and T4
S/S : Dysphagia
Enlarge thyroid
All s/s of hypothyroidism (decrease metabolism)
Nsg Dx : Knowledge Deficit
Activity Intolerance
mental retardation
Meds : Single morning dose of Synthroid for “LIFE” – oral thyroxine and Vit D as
ordered to prevent M. retardation
Hx Teachings :
ENDOCRINE GLANDS
- 8 glands (ductless)- they secrete the hormone directly to bld stream
1. Pineal Gland
2. Pituitary Gland
3. Thyroid Gland
4. Parathyroid Gland
5. Thymus Gland
6. Pancreas
7. Adrenals
8. Gonads (testes & ovaries)
Pancreas DM
PANCREAS
Islets of Langerhans
Absence Deficiency
(DM Type I) (DM Type II)
IDDM NIDDM
MODY – DM III
D2 >20 yrs
D3 Beginning Retinopathy
D4 w/ calcification of arteries
D5 DM w/ HPN
H Diabetes Cardiopathy
R Diabetes Retinopathy
DIABETES MELLITUS
Cause: unknown
R. factors : Autoimmune
Genetic
Stress
S/S : Polydipsia
Polyuria
Polyphagia – the stave cells send message to the brain to eat more
Wt loss
PI :
Correct the deficiency- HOW?
Diet : well balance diet – CHO – 50-70% (main source of energy and sugar for DM pt.)
Insulin – for Type 1
Hypoglycemia Most Approximately to Occur
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
Antidiabetic Agent;
Exercise – it will decrease insulin requirement (in pregnancy/stress – Increase insulin req)
• +300Kcal;
• Insulin Requirement (dose will be adjusted on 2nd & 3rd Trimester);
EFFECTS
MOTHER BABY
Macrosomia
Hyperglycemia Hypoglycemia
Therefore pre-term birth RDS
Complication: Uterine Atony Congenital Defects
COMPLICATION
DKA HHNK
Risk Factors :
Dizziness
Drowsiness
Difficulty Problem Solving
Decrease Level of Consciousness
+ Cold Clammy Skin, Diaphoresis
If unconscious – D50
PI : #1 AIRWAY
#2 Fluid
Regular Insulin
DIABETES INSIPIDUS
(Pituitary Glands – 3 lobes)
FSH OXYTOCIN
(follicle stimulating Hormone) ADH
ACTH
(adrenocorticotropic hormone)
LH (luteinizing hormone);
GH (growth hormone);
Prolactin
PITUITARY GLAND
Pituitary Tumor
Head Trauma
Injuries
MP : Deficiency in ADH leads to fld excretion, therefore s/s same with DM EXCEPT : POLYPHAGIA
Polyuria – 21 L/day
Polydypsia
LAB DATA :
PI : Administer IV Fluids
Meds - Synthetic ADH - Vasopressin – IM
Desmopressin – INTRANASALLY- one hole of nose only
Lypressin - -do-
convulsion;
seizure;
HPN
PI : FLUID RESTRICTION
Drugs – DIURETICS + ANTIHPN – if cause by TUMOR – PREPARE PT FOR SURGERY
IF after surgery – POLYURIA – report ASAP – sign of DI
PITUITARY
GROWTH HORMONE
DEFICIENCY EXCESS
PI : Safety
Meds - Parlodel – decrease secretion of growth hormone
If related to tumor : surgery
GIGANTISM
(long slender extremity)
MP : Cardio & Eye disorder (complication) MP : XXY Pattern (an extra X chromosome)
Scoliosis X chromosome – FEMALE COMPONENT
of HUMAN BODY
ADRENAL/SUPRARENAL
Common: Male and Female Female (bet. Age 30-60) Female (30-50)
S/S: Dec Bld Sugar (hypoglycemia) INC BP, NA ALL S/S OF CUSHINGS
Dec Na (hyponatremia) DEC K + EXCEPT HYPERGLYCEMIA
Dec BP Moonface, Hirsutism,
INC K (hyperkalemia) Buffalo Hump, Pendulous Abdomen Hypertension
Lability of Mood (mood swings) Polyuria, Polydipsia
Depression Cardiac Arrythmias – due
COMPENSATORY of MSH – Inc w/c Trunkal Obesity / thin Extremities to dec K
Leads to “Bronze-Like Skin Pigmentation” Hypertension
Decrease Resistance to Infxn
Hypotension, Weak Pulse
Weight loss, Fatigue, Muscle weakness
Nausea, Anorexia, Vomiting
Hx of frequent Hypoglycemic Rxn
Lab Data : Decrease Cortisol Level Increase Cortisol Level Hypokalemia – due
Hyponatremia Hypernatremia metabolic Alkalosis
Hypoglycemia Hyperglycemia Inc Urinary Aldosterone Level
Hyperkalemia Hypokalemia Decrease K
Nsg Dx :
Fluid Vol. Deficit Fld Vol. Excess Risk for Injury
Fld & E imbalance Fld & E imbalance Fld & E Imbalance
PI :
Meds are FOR LIFE Prevent accident & Falls Diet : Low Na, Inc K
Prevent exposure to Infxn Protect client exposure to Infxn
Provide rest periods – prevent fatigue Minimize stress in environment Administer SPIRONOLACTONE
Monitor I & O, weigh Daily MIO & weigh Daily (aldactone) & K supplements
As Rx
Provide small, frequent feeding high in Monitor V/S, observe for HPN &
CHO, Na and CHON to prevent edema
Hypoglycemia & Hyponatremia
Use of Table salt tablets (if Rx) or ingestion Surgery – prepare pt if cause
Of salty foods (potato chips) by pituitary tumor or hyperplasia
if experiencing Inc. sweating
Post Surgery:
poor wound healing;
report s/s of Addisonian Crisis –
severe HYPOTENSION
ADDISONIAN CRISIS
- severe exacerbation of Addison’s dses caused by acute adrenal insuffieciency
THYROID
T3 & T4 Calcitonin
- responsible for maintenance of METABOLISM - deposit Ca @ bones
DEFICIENCY EXCESS
HYPOTHYROIDISM HYPERTHYROIDISM
Adult: Myxedema Grave’s Disease, Basedow’s or Parry’s Dses
Children: Cretenism
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
Causes:
congenital genetic
surgery autoimmune
autoimmune tumor
S/S :
LAB DATA :
PI :
Promote a EUTHYROID STATE same
c. Maintain vital funx: correct hypothermia – maintain Quite & relaxing Activity
adequate ventilation
d. Provide comfortable, warm environment Provide a COOL ENVIRONMENT
e. Increase flds and high fiber foods to prevent
constipation,. Admin stool softener as Rx DIET : High in CHO, CHON, CALORIES
f. Meds: thyroid hormone replacement – take daily Vit & Minerals w/ supplemental
dose in AM to avoid insomnia feedings bet meals & at HS
Monitor THYROTOXICOSIS – tachycardia NO STIMULANTS
Palpitations, nausea, vomiting, diarrhea,
Sweating, tremors, dyspnea Protect eyes w/ dark glasses & artificial
tears
MEMORRHAGE – whether the dressing is dry or intact – its not a confirmatory that there
is no bleeding.
To check, slip your hands at the back of the neck (bec of principle of gravity)
Damage Laryngeal Nerve – to assess, ask pt to talk past surgery and if pt has APHONIA – provide
communication aids – paper and pencil
Parathormone
S/S :
PI : a. Safety same
a child w/ PKU was admitted, w/c of the ff statements made by the mother
indicates a need for further instruction – “my child loves to drink milkshakes”
– chon- w/c has INCREASE Phenylalanine;
a pt post thyroidectomy develops tetany, the nurse anticipates that the doctor will
most likely order – Ca Gluconate;
a pt is to receive NPH Insulin at 8AM, when shld the nurse expect to have
hypoglycemia – in the late afternoon;
w/c of the ff statements made by the diabetic pt would indicate the need for
further teaching – “I will be hypoglycemic if I experience emotional stress”.
GENITO-URINARY
General Consideration
when performing assessment of Genito-urinary system, use open-ended question- bec some pt are
not comfortable talking genitals;
explain the meaning of terminologies;
ask the patient what symptoms bother him/her the most;
infants are unable to concentrate urine until the age of 1 – therefore – adequate milk intake if baby
has 6-8 diapers /day;
bladder sphincter control develop at around 2 yo (therefore, bladder trng comes after bowel trng –
15-18 mos of age)
a. frequency
b. urgency
c. hesitancy
Reportable s/s :
Key points :
WILM’S TUMOR
- congenital tumor at the kidney
- common in L Kidney and
children below 5 yo
Lab Data :
CT Scan
IVP
NO INAVSIVE LAB/ Procedure
NO BIOPSY
S/S
BP : Decrease or N INCREASE BP
LAB DATA
(+) Proteinuria, severe - >10mg in 24 hrs (+) Proteinuria - <10 mg/ 24hrs urine
PI :
Check BP
Maintain Fld Balance
Meds : NO Antihypertensive Antihypertensive
(+) Steroids Diuretics
(+) Antibiotics
DIET :
Turn Patient frequently – because pt w/ edema are prone to skin integrity like pressure sore formation
CYSTITIS
- Infection of the bladder
- Ascending infection caused by E. Coli (from feces) or Pseudomonas
RF :
Wearing silk underwear (does not absorb moist); - use COTTON
Bubble bath
Prolong driving
Common in FEMALE – due to size (short) urethra
S/S:
FREQUENCY, URGENCY & HESISTANCY + Burning sensation on urination (dysuria)
RENAL FAILURE
ACUTE CHRONIC
Causes PHASES :
Pre-renal Factors – those that dec bld circulating vol. – SHOCK;Phase I: RENAL INSUFFICIENCY
Intra-Renal – dses condition of the kidney eg. AGN
Post-Renal – those that causes obstruction eg. Kidney stones Polyuria
Nocturia
Polydipsia
Phases of ARF
PHASE II : MILD RENAL DAMAGE
OLIGURIC PHASE
- decrease urine output that is less than 400 ml/24hr (OLIGURIA) There will be INC BUN & Crea
- Dec NA & Inc K
RENAL FAILURE
DIURETIC PHASE
- Inc urine output (4-5L/day) All s/s + Anemia & HPN
- Dec Na & K
ESRD
RECOVERY PHASE
- renal funx normalizes (1-2 yrs) Azotemia & Uremia –
accumulation
of waste products
DIALYSIS
PERITONEAL HEMODIALYSIS
Teachings: anastomosis of artery & vein (internal access) – less prone to infxn
RENAL TRANSPLANT – s/s of complication : FLANK PAIN, FEVER, TENDERNESS, HPN - REPORT
BPH
- glandular enlargement of the prostrate
- common in males above 40 yrs old
S/S :
Decrease size and force of urinary stream
Nocturia
Frequency, hesitancy and urgency
LAB DATA:
Digital rectal exam – once a yr for pt 40yo and above
gloves, ky jelly
position: Sim’s
To prevent cystitis, w/c of the ff the nurse must instruct to the pt to do – take a
bath using the shower rather than bubble bath;
For early detection of prostrate CA the nurse shld emphasized – digital rectal
exam annually to screen for prostrate CA in men 40 yo and above;
In a pt with BPH, the nurse shld expect that the pt will probably have the
symptoms – residual urine of more than 50 ml;
A male pt has an arteriovenous fistula in his L forearm, w/c behavior would indicate
that the pt needs further instruction in self care – he wears a watch on his L
wrist;
EENT
General Consideration
Explain to the patient there there will be no or little discomfort when performing EENT exam;
Explain the methods of assessment to the patient;
Hearing Loss
Pain – if pain subside or (-) – rupture of ear drum
OTITIS MEDIA
- infection of the middle ear
RF :
S/S :
PAIN – Pulling
Tugging
Crying when lying on the affected ear
Lab Data :
OTOSCOPY – revealed – reddened, bulging tympanic membrane
Nsg Dx : Infection
Sensory – Perception Alteration
PI : Treat Infection (antibiotics – 7-10 days) – if does not heal – possible MYRINGOTOMY
S/S :
LEUKOCORIA – “cat’s eye reflex”
- whitish or grayish discoloration of the pupil
LAB DATA : PE
Opthalmoscopy
RF:
Aging (above 40) Aging (above 40) Aging (above 70)
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:
S/S : NO Pain
Blurring of vision – because of floaters
PI : Immediate Bed rest – AFFECTED SIDE TOWARDS THE BED – to allow the connection of
DETACHED PART
Prepare Pt for Surgery: SCLERAL BUCKLING – use of laser to reduce inflammation and
when inflammation subside, the
detached retina portion will be attached
thru scar formation.
POST SURGERY :
GLAUCOMA
MP : INCRASE IOP due to obstruction in the outflow of acqeous humor or could be related to
forward displacement of the iris.
S/S :
LAB DATA:
Gonioscopy
Opthalmoscopy
Perimetry – measures visual field
PI : TO DECREASE IOP
How:
LAB DATA:
b. Opthalmoscopy
w/c Nsg Dx is considered a priority for a pt with Meniere’s Dses – Risk for Injury
Post Cataract Extraction : how shld the nurse position the pt – UNAFFECTED SIDE
to minimize edema;
GENERAL CONSIDERATION
Provide privacy
Ask the pt when he 1st notice the S/S
Eg. LIVER CIRRHOSIS – when did you notice that your eyes turns yellow?
PEDIATRIC CONSIDERATION
Cereals
Fruits
Vegetables
Meat
Table foods
REPORTABLE S/S
Vomiting
Abdl Pain (if more than 6hrs) – R/O rupture of the bowel
Tarry Stool – indicates bldg (upper GI)
Fever, Tachycardia, Dehydration – indicative of SHOCK
Hypotention
KEPOINTS…
Ex. “bruit” – abnormal vascular sound w/c indicate abdml aortic aneurysm
DIARRHEA/ AGE
- usually asso w/ NORWALK (common in ship), ROTAVIRUS and CLOSTRIDIUM DEFFICELE
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
LAB DATA :
Nsg Dx :
Diarrhea
Fluid Volume Deficit
Complication :
LAB DATA :
Administer flds
Antibiotics/ Antidiarrheals ( dosage: if less than 10 kg, therefore X100)
Health teachings – crackers, juice, water
Feeding : Thickened
Prepare pt for surgery : NISSINFUNDOPLICATION – part of fundus will be sutured to
esophageal area to tighten
Effective: if (-) vomiting and(-) reflux and heartburn
POISONING
INTERVENTION:
“if unknown substance was taken” – bring bottle or foil for proper identification
TYPES:
How:
a. Use fingers or tongue blade
b. Syrup of Ipecac – administer w/ glass of H2O – make sure that all taken will be
vomited – bec it is cardiotoxic (after 1hr – can repeat)
dosage: CHILDREN – 15 ML
ADULT - 30 ML
CLEFT
LIP PALATE
MP: Non-fusion of facial process Non-fusion of Palative Processess (soft & hard)
(congenital) (congenital)
PI : Nutrition
Safety
Prepare for Surgery
Surgery :
Chiloplasty Palate Uranoplasty
Post Surgery:
PYLORIC STENOSIS
- congenital
- hypertrophy (“kumapal”) of the pyloric sphincter (bet stomach & intestine)
S/S :
If sitting : 4-5 ft
If lying down : 1 foot
Feeding should be thickened then AFTER FEEDING, place to RIGHT SIDE LYING SEATED
at car seat – to facilitate the entry of food from stomach to duodenum
• OLIVE-SHAPE MASS
• VISCIBLE PERISTALTIC MOVEMENT – usually from L to R of the abdomen – w/c can lead to DHN
LAB DATA :
PI : Nutrition
Surgery – FREDET-RAMSTEDT or PYLOROMYOTOMY – incision at pyloric sphincter
CELIAC DISEASE
- GLUTEN –INDUCED ENETEROPATHY
- Genetic predisposition
- Life-time disorder
MP : Intolerance to GLUTEN
LAB DATA : Diagnostic Test : GLUTEN CHALLENGE – 3-4 mos – give gluten rich food
And if there is malabsorption, therefore (+) CDses
PI : Dietary Modification : AVOID GLTUEN RICH FOOD : Barley, rice, oats, wheat
Tx : Give Enema
Meds : Laxative
Surgery – SOAVE Surgery – resection with end to end pull through
INTUSSUCEPTION
Nsg Dx : Constipation
Altered Elimination
Types :
Atresia – “narrowing”
Fistula – connection
PI : Safety
Airway
Keep child NPO – just give pacifier (if feeding OK – use sterile H2o instead NOT GLUCOSE)
Tx : Surgery
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;
PEPTIC ULCER
RF : Stress
Smoking
Salicylates or NSAIDS
Helicobacter Pylori
Zollinger-Ellison Syndrome (gastinoma) – tumor of the stomach – due to increase HCL acid
RF : same same
Nsg Dx : PAIN
PI : Relief of Pain
NO ASPIRIN
GASTRIC SURGERY
VAGOTOMY
PARTIAL GATRECTOMY – Billroth I (BI) and Billroth II (BII)
TOATAL GASTRECTOMY
COMPLICATIONS:
PERNICIOUS ANEMIA – due to decrease INTRINSIC FACTOR w/c came from stomach;
RF : With familial Predisposition Common in those LOW FIBER Diet Related to Genetics
Smoking as Protective Effect Common in Aging
Common in Obsessive-Compulsive
Or Stress Related or to “perfectionist”
MP :
Nsg Dx : PAIN
Altere Elimination: Diarrhea
PI : Relieve Pain
Meds: Steroids
Anticholinergic
Antidiarrheals
Antispasmodic
DIET : Low Fiber and Low Residue – for Ulcerative and Chron’s
HEMORRHOIDS
MP Varicosities of the ANAL SPINCHTER
RF
PREGNANCY
PROLONGED STANDING
PORTAL HPN – hepatic enceph and liver cirrhosis
GRADE
I Small Area
II Large Area – reduces spontaneously
III Entire Area – manual reduction
IV Entire Area – irreducible
TYPES
S/S Pruritus
Pain
Bleeding
STOOL SOFTENER
SURGERY
PANCREATITIS
- AUTODESTRUCTION OR AUTODIGESTION of the pancreas
RF #1 Alcoholism
#2 autoimmune
High Fat Diet
Biliary Dses
LAB DATA Elevated Serum Amylase (N56-190 u/L that normalize in 2 wks)
Nsg Dx PAIN
PI Relieve PAIN
CHOLELITHIASIS CHOLECYSTITIS
Combine or usually come together in a pt
RF Fat same
Female
Fertile
Forty
flatulence
Nsg Dx PAIN
PI Relief of Pain
meds : DEMEROL
diet: LOW FAT
2) CHOLECYSTECTOMY – R SUBCOASTAL
- complication: “Pneumonia”
– report rusty-colored sputum
hx teaching: TURNING, COUGHING, DEEP BREATHING
HEPATITIS
MP Inflammation of the Liver
TYPES
A B C D E
STAGES OF HEPA B
Nsg Dx Infection
Alt Skin Integrity
Body Image Disturbance
PI Tx for Infection
a. Meds : HEPATOPROTECTORS
DIURETICS
LIVER CIRRHOSIS
- scarring of liver tissues
TYPES
a. pt prone to bleeding;
b. malnutrition – no cho metabolize
c. edema – due to fld retention (bec of dec albumin)
d. Flds & e imbalance
PI SAFETY
HOW?
COMPLICATIONS:
A pt w/ appendicitis was admitted, of ALL the ff written orders, w/c shld the nurse
prioritize – Administration of Antibiotics;
w/c statement if made by a pt w/ cirrhosis is a risk factor for having the disease –
“I drink 2 glasses of alcohol /day”;
the priority nsg care post common bile duct exploration – preventing hypostatic
PNA;
the priority nsg dx for for pt w/ acute pancreatitis – Altered nutrition less
than body requirements
NEUROLOGY
DECORTICATE – abnormal FLEXION
GENERAL CONSIDERATION
#1 Range of Motion
#2 Joint Stiffness
#3 POSTURES
PEDIATRIC CONSIDERATION
c. Assess for presence of URTI – could be sign of Meningitis, Hemophilus influenza, Otitis Media
d. Assess child for S/S of anxiety
- bed wetting
- nail biting (N up to 4 yo)
- head banging
- excessive thumb sucking
CONCUSSION – jarring of the brain, “na-alog” w/c could lead to s/s of LOC in 24-48 hrs
6 – OBEYS COMMAND
5– ORIENTED 5 - LOCALIZES PAIN
4 – OPEN SPONTANEOUSLY 4– CONFUSED 4 – WITHDRAWS FROM PAIN
3 – OPENS TO VERBAL COMMAND 3 – INAPPROPRIATE 3 - DECORTICATE RIGIDITY
2 - OPEN TO PAIN 2 - INCOMPREHENSIBLE 2 - DECEREBRATE RIGIDITY
1 - NO RESPONSE 1 - NO RESPONSE 1 - NO RESPONSE
SCORE OF 15 : pt is awake
CRANIAL NERVES
III. OCCULOMOTOR
IV. TROCHLEAR Eye movement - 6 cardinal direction of gaze
VI. ABDUCENS (if abnormal look for DIPLOPIA)
TEST : ROMBERG’S TEST - stand erect, close eyes, observe for balance
IX. GLOSSOPHARYNGEAL
X. VAGUS SENSORY – Posterior Taste 1/3 Of The Tongue
Related to Birth Injuries affecting the BRACHIAL PLEXUS – nerves at axilla portion
c) impaired mobility
PI AIRWAY
(keep TRACHEO at bedside)
TX
Ex. Aunt, Female Sibling, mothers, female members of the family – (bec transmission: X linked recessive)
CEREBRAL PALSY
- Permanent, Fix (non-progressive) neuromuscular disorder characterized by abnormal
muscle movement.
Cause Unknown
PI SAFETY
a. Leg braces
b. Meds : Anticunvulsants, Muscle Relaxants
c. Prepare child for SURGERY – release of TENDON OF ACHILLES – to promote mobility
d. Refer child to : PT – for gross motor movement – walking
OT - for fine motor – to open a bottle of soft drinks
HYDROCEPHALUS
NOT A DISEASE but a manifestation of an existing disorder
SIDE NOTES: FLOW OF CSF (N amt : 100- 200 ml) – rich in glucose
From Lateral Ventricle it goes to Foramen of Munroe then to 3rd Ventricle then to Aqueduct of Sylvius then it moves
to F. of Luschka and Magendie going to 4th Ventricle then it goes back to subarachnoid spaces of brain.
S/S OF HYDROCEPHALUS
PROJECTILE VOMITING
IRRITABILITY
ENLARGED HEAD – N Head Circumference : 33-35 cm (chest circum: 31-35 cm)
SEPARATION OF SKULL BONES
SEIZURES
SUNKEN EYES – Can Progress To Bossing Sign
MACEWEN SIGN – crack pot sound upon knocking the head
PI SAFETY
Meds Diuretics
Anticonvulsants
TYPES
SB OCULTA SB CYSTICA
NO SAC W/ SAC
W/ DIMPLE or TUFT OF HAIR
SUB TYPES:
LAB DATA Amniocetesis – test for ALFA FETO CHON – if INCREASE – Neural Tube Defect
If DECREASE – Down Syndrome
CT SCAN
PExam
INCREASE ICP
ICP above 15mmhg (N 0-10)
Mild elevation : 11 – 20
Moderate : 21 - 30
Severe : 31 and above
RF Hydrocephalus
Space Occupying Lessions
Brain Tumor
Trauma
S/S
3. Vomiting
PI To decrease ICP
MENINGITIS MENINGISMUS
Nsg Dx Infection
Risk For Injury
PI Safety
Seizure Precaution
Tx the Infection
Type of Infcetion:
REYE’S SYNDROME
Non inflammatory, non recurring but TOXIC ENCEPHALOPATY and HEPATOPATHY
(CNS) (LIVER)
CVA/ STROKE
MP Decrease Oxygen to brain cells
TYPES
THROMBOSIS
EMBOLISM
HEMORRHAGE
INFARCTION
RF
atherosclerosis
hpn
obesity
smoking
stress
age/ gender
a. TIA – brief period of neurologic dysfunction that last less than 24 hrs (between episode, pt is
N);
b. STROKE IN EVOLUTION – there s/s like: facial paralysis
Muscle weakness
- above s/s could last 2-3 days
c. COMPLETE STROKE – there is FOCAL s/s
2. RELATED TO LOBES
Hemianopsia loss of half of the visual field (eg. Pt consumes half of the food at plate);
Aphasia Expressive – inability to find right words to say (damage to Brocka’s Area);
- pt can say right words – mgt: picture board
Position Semi-fowler’s
Elevated
Meds Antihypertensive
Diuretics
Antilipimic Agents
Anticonvulsants
Thrombolytics – if (+) thrombus – to dissolve clots
DIET Low Na and Cholesterol
Surgery Craniotomy
GBS MG
MP Inflammation that leads to destruction of Peripheral Nerves Deficiency in ACTH Receptor Sites –
90%
w/c leads to: ASCENDING GBS Or Def. in ACTH –
“neurotransmitter”
DESCENDING GBS
Mixed Type GBS
ASCENDING GBS - #1 Clumsiness that eventually lead to S/S Muscle weakness w/c begins at
face
muscle weakness & resp. depression therefore, Diplopia and Ptosis –
which
progresses to MASK-LIKE face which lead
to
respiratory depression
(descending paralysis – start at face – “NO
telebabad”)
MYASTHENIA GRAVIS
COMPLICATIONS
MULTIPLE SCLEROSIS
Common among women – especially white
There is destruction of MYELIN SHEET at CNS , therefore generalized muscle
weakness
Eg. “I know I will be eventually confined in the wheelchair
LAB DATA #1 MRI – specific test for MS – it localizes the area of plaque formation or the area of
dyemlination
#2 CT SCAN
DRUGS STEROIDS
Anticonvulsants – dilantin
Muscle relaxant – Baclofen
Bladder Stimulants – Urecholine (bethanicol)
PI AIRWAY (tracheostomy)
SUPPORTIVE
Refer to Geneticist
SIDE NOTES:
A Recessive : Cystic Fibro, Sickle Cell, Apalstic/Fanconis – either or both parents are (+) for trait NOT
DSES
A Dominant : Retinoblastoma, ALS – either father or mother (+) for disease or trait
X Link Recessive : Hemophilia, Color Blindness, Duchennes Muscular, G6PD Dses – mother (+) trait NOT DSES
and transmit to SON
TYPES
C5 – C8 - Complete quadriphlegia
PI SAFETY
COMPLICATIONS OF SPINAL INJURY : AUTONOMIC DYSREFLXIA – due to full bladder and bowel
what to keep at bedside: CATHETER - TO KEEP THE BLADDER EMPTY, BEC IF FULL IT WILL TRIGGER THE ANS
• When taking care of pt w/ C4 Spinal Injury, w/c equipment shld the nurse
keep @ the b.side – Urinary Catheterization Set;
MUSCULO
CLUBFOOT DEFORMITY
MP Congenital
Foot twisted out of place
Types
Talipes Varus – “inversion”
Talipes Valgus – “eversion”
Talipes Equinus – “tiptoe”
LAB DATA PE
Xray
PI Promote Mobility
#1 MANUAL MANIPULATION
#2 SEREAL CASTING – every 1-2 wks til position normalizes
#3 DENNIS BROWN SPLINT – 2-3 months
CAST : assess for s/s of neurological damage: Capillary refill – if more than 3 sec. -
REPORT
EDEMA
Skin Color/ nailbed
MP Maldevelopment of the Hips – that involves the acetabulum, head of femur or both
NO ADDUCTION OF LEGS!
FRACTURES
TYPES Open (compound) – bone tears the skin – therefore open: risk for infection
CLOSE – skin intact
S/S #1 Deformity
#2 Pain
#3 Edema
#4 CREPITUS – sound created when two bone surface rob each other
a. Splinting;
b. Casting – check for edema – elevate the affected areas;
- check skin color – capillary refill time
- check for presence of blood stained
SCOLIOSIS
MP Lateral Deviation of the Spine
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
HX Teaching
Avoid : Bending
Jumping Rope
Playing Tennis
Trampoline
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
Nsg Dx SAFETY
How?
ARTHRITIS
MP
S/S PAIN
Inflammation
Morning Stifness
Stages of Rheumatoid A.
STAGE 1 – no Disability
STAGE 2 – with Interference To ADL
STAGE 3 - with major compromise of funx
STAGE 4 - incapacitation
Nsg Dx PAIN
Impaired Physical Mobility
PI Relief of Pain
a. Warm Bath;
b. MEDS : ASA - Antiinflammatory
STREROIDS
c. exercise: ROM
GOUTY ARTHRITIS
NSG DX PAIN
Impaired Physical Mobility
PI Relief of PAIN
OSTEOARTHRITIS
A degenerative joint disease that involves the weight bearing joints – elbows & knees
LAB DATA
xRAY
Nsg Dx PAIN
Impaired Physical Mobility
PI Weight Control
Nsg Dx PAIN
Altered Tissue Perfusion
Risk For Injury
Drugs Steroids
TRACTION
PRINCIPLES T – rapeze bar
R – equires free hanging weights
A – nalgesic
C – iculation monitoring
T – emperature monitoring
I - nfection prevention
O – utput and input monitoring
N – utrition
S – kin Assessment
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;
a pt is using CRUTCHES for the first time, w/c action reflects a need for further
instruction – the pt bears his/her wt with his/her axial;
a pt on buck’s traction of the R femur ask the nurse how he can possibly move
around. What can the nurse advise the pt – you can hold on to the trapeze bar
while moving;
w/c of the ff can possibly indicate the presence of abnormality in an
adolescent – uneven hemline – scoliosis;
when assessing an infant, w/c of the ff needs to be reported – extra gluteal folds;
post spinal fusion –ROBAXIN –is given for w/c of the ff purpose - to decrease
muscle spasm;
a child has hip spica cast upon discharge, w/c statement of the father indicates
further instruction – “ I will hold on to the bar bet his legs to help move
him”
INTEGUMENTARY SYSTEM
Burn – triage : face and perineum (priority)
BURNS
CLASSSIFICATION:
According to Damage
FULL THICKNESS
THIRD DEGREE 4TH DEGREE
BURN TRIAGE
Priority : Burns of FACE
PERIMEUM
UPPER & LOWER EXT
Burn related to Child Abuse
Chemical – Fire
THINK: R escue
A larm
C onfine the Fire
E xtinguish the Fire
B – reathing – Airway
U – rine output monitoring
R – esuscitation of Fluids
N – utrition
S – ilvadene Ointment
Complications
PI Vaccination
Use long sleeve
Remove ticks w/ twizers – upward straight motion
Meds Chloramphenicol
Tetracycline
DERMATITIS
Crusting
Pruritus or itching
Viscicles
RASH Non Pruritic Begins w/ face & downwards Face & downwards
Rose pink – begins w/ trunk
Progressing outward
Bed rest
Antibiotics
Antipyretic
Acyclovir
Cervical Ca – complication of
Herpez
Annual pap smear
TRICHOMONIASIS MONILIASIS/CANDIDIASIS
Caused by TRICHOMONAS Vaginalis Albicans
A nurse admits 8yo brought by her mother. Upon assessment, the nurse finds
rounded rings of rash. This is indicative of – lyme’s dses;
During the immediate 24hrs pot burn, w/c of the ff is the priority – administration
of fluis;
A pt tells the nurse that he notice small blisters on his private parts. This is
indicative of – HERPEZ
A pt with CA of the cervix was admitted with the ff data: w/c one indicates a
possible risk factor – previous tx for herpes;
CANCER
Cause Unknown Theory of USE - Overuse, Underuse, and Abuse
Male:
a. Testicular Self Exam – mothly – begins age 16 yo- target are high school
Female:
COMMON S/S
A pt w/ bipolar episodes is ready for discharge when – she can comply with
units activities;
The nurse would suspect that the child is a victim of abuse if he – keeps quiet
while an IV is inserted;
the initial care plan for a pt with Anorexia Nervosa would require the pt to –
remain in public place 1 hour after meals;
where shld the nurse put the pt on early alcoholic withdrawal – well-lighted room
near nurses station
A Mother Is Crying Besides her baby, she said “I feel so sorry I couldn’t hold her” –
let her stroke the baby;
6wks pregnant woman ask the nurse about the signs of pregnancy – w/c one is
expected at this time – frequent urination;
the nurse notes mirror image in the fetal monitor – this could be related to
FETAL HEAD COMPRESSION;
TIPS PEDIA
the most appropriate toy for 18 mos old child – carriage w/ a doll;
the appropriate room mate for an 8yo girl w/ leukemia is – 6 yo with hemophilia;
in a 3yo child – w/c of the ff shld the nurse assess during admission – special
words used for objects and routines;