MOTHER/BABE/ FAMILY CARE

-First Trimester: 1-12 weeks, heart, spinal cord, nail beds, spontaneous movements, reflexes present, bone forming,
heartbeat audible by Doppler, bones and teeth forming, kidney forming, Parent needs to accept pregnancy
-Second Trimester: 12-24 weeks, Hearing, eyes, pupils, lids work, passive immunity transferred from mom at 20 weeks,
lung surfactant present, developed biorhythms, heartbeat audible, brown fat, liver and heart functioning. Parent needs to
accept baby
-Third Trimester: (24-40 weeks), kicks, vernix caseosa fully formed, creases on soles of feet, fetal hemoglobin starts to turn
to adult hemoglobin (about 20%), SC fat, lanugo decreases, turn head down. Parent needs to accept parenthood.
-Common emotional responses are: ambivalence grief, narcissism (self-centered), introversion, extroversion, stress, couvade
syndrome (men getting the nausea, vomiting, and backache), body image and boundary confusion, emotional labilitym and
changes in sexual desire.
-McDonald's Rule: method of determining fetal growth by measuring fundal height from notch of symphasis pubis,
accurate only between 20-31st weeks,
-Monitor: 1)Fetal heart rate (between 120-160), 2)Fetal movement, 3) Ultrasound 4) ECG's 5) MRI
6)amniocentesis 7)Percutaneous umbilical cord sampling
Complications of Pregnancy
-Vaginal Bleeding:may lead to hypovolemic shock, could be cause by miscarriage, ectopic preg, premature cervical dilation,
placenta previa, premature separation of placenta, preterm labor.
-persistent vomiting, chills and fever (Interuterine infection?),
- sudden sharp increase in wt. near the end of preg = water retention or beginning of preeclampsia
-sudden escape of clear fluids from the vagina, (ruptured membranes, uterine cavity no longer sealed against infection,
umbilical cord may prolapse, fatal head no longer fits snugly, women may confuse this with stress incontinence.
-abdominal or chest pain: Uterus expands painlessly, may be ectopic pregnancy, placenta separation, preterm labor,
appendicitis, ulcer, pancreatitis, PE

increase or decrease in fetal movement,

exposure to teratogens (cigarettes, alcohol, radiation, lead, tetracycline, hyper/hypothermia): TORCH tool stands
toxoplasmosis, rubella, cytomegalovirus, herpes. 'o' stands for other infections, such as syphilis, hep B, HIV,

Hydramnios: excessive amniotic fluid, can cause fetal malpresentation, premature rupture of membranes, preterm labor,
prolapsed cord,

Post-term pregnancy: longer than 42 weeks, can be caused by taking salicylates fro headaches or RA, can lead to
meconium aspiration, baby may get to big to pass thru canal, or can lead to lack of growth, lack of O2, nutrients fluid

Pseudocyesis: false pregnancy symptoms in non-pregnant people.

- Isoimmunization (Rh incompatibility): Mom who is Rh- carrying Rh+ baby, as dad is Rh+. Rh is an antigen, so when
baby who is Rh positive passes the blood to mom, she is invaded by foreign agent (antigen). Mom's body reacts and forms
antibodies to the antigen, These antibodies pass into fetal blood and destroy the whole red blood cell where Rh lives. This
can cause hemolytic disease in newborn. Mom's blood only is exposed to fetus's blood if villi rupture, during amniocentesis,
but a lot of blood exchange during birth, so these antibodies are formed after birth in the first 72 hours.
-Pregnancy induced hypertension (PID), (aka Toxemia) : Where Vasospasm occurs during pregnancy, . 5-10% of all
pregnancies. NO known cause, Occurs more in primiparas and women under 20 or over 40, Symptoms: Proteinuria, Rapid

wt. Gain, swelling of face/fingers, flashes of light/dots behind eyes, blurred vision, headache, decreased urine output.
Classified as
1) gestational hypertension: BP over 140/90, no proteinuria, or edema,,, low dose aspirin, may develop HTN later in life
*** Nursing interventions for women with mild hypertension: Promote bed rest, good nutrition (decreased salt), Provide
emotional support,
2) mild pre-eclampsia: 140/90, has proteinuria +1 or +2, may have edema.
*** Nursing Interventions+ Promote bed rest, monitor maternal well-being, monitor fetal well-being, support nutritious
diet, administer meds (antihypertensives IV magnesium sulfate,
3)severe pre-eclampsia: BP over 160/110, Proteinuria +3 or +4, severe edema, epigastric pain, N+V, SOB, blurred vision,
headache
4)eclampsia: Seizure or coma occurs d/t cerebral edema, 20% mortality d't renal failure, circ collapse, cerebral Hemorrhage,
fetus usually dies d/t acidosis
*** Nursing: Tonic-Clonis seizures, maintain airway assess o2, turn on side, apply fetal heart monitor, check for vag
bleeding, birth may be induced, may have post-partal hypertension.
Not all three need to be present for diagnosis, hypertension and proteinuria most significant. Edema only sig. If increased
B.P & proteinuria or signs of multi organ system involvement.
***A systolic blood pressure greater than 30 mmHg and diastolic B.P greater than 15 mmHg is a helpful rule due to varying
B.P in women.
Nursing Interventions: Bed rest
-always in the lateral recumbent position to avoid uterine pressure on the vena cava & to prevent supine hypotension
syndrome.
Good nutrition, (increased protein and moderate sodium diet). Emotional support. With eclampsia- monitor fetal well-being
with Doppler.If a seizure occurs maintain a patent airway and administer oxygen.
Valium as an emerg. Measure.
HELLP SYNDROME
-variation of PIH.
-Stands for hemolysis elevated liver enzymes and low platlets.
S&S
-nausea
-epigastic pain
-malaise
-RUQ pain
-lab results hemolysis of RBC
-increased liver enzymes due to hemorrhage (observe for bleeding).
Treatment: transfusion of plasma and platlets
Complications of HELLP: liver hematoma, hyponaturemia, renal failure & hypoglycemia
5) Ineffective Uterine contractions: (hypotonic, hypertonic, uncoordinated)
6) Contraction rings: constriction ring, where there is a horizontal indentation across abdomen from excessive retraction of
upper uterine segment.
7) Precipitate labor: when contractions are so strong, baby is born in fewer than 3 hours, may lead to premature separation
of placenta, hemorrhage, fetal subdural hemorrhage
8) Uterine rupture: occurs usually when an old scar from past c-section tears, or prolonged labor, multiple gestation,
obstructed labor etc. Women will feel severe sudden pain. Tear can be through one or all layers. Look for signs of shock,

hemorrhage.
9) Prolapsed Umbilical cord: loop of the umbilical cord slips out before baby. Leads to cordal compression, Admin O2,
10) drop in BP= could be caused by baby's pressure on vena cava. Position mom on left lateral side and re-check BP
Stages of Labor and Delivery
First Stage:
a) Latent stage:
begins at onset of regularly perceived uterine contractions and ends when rapid cervical dilation begins.
Contractions are mild and short (20-40 seconds).
Cervical effacement occurs, and dilates from 0-3 cm
Lasts approx. 6 hours in nullipara, and 4.5 in multipara

b) Active stage:
further cervical dilation from 4-7 cm
contractions now 40-60 seconds every 3-5 minutes
lasts 3 hours in nullipara, and 2 hours in multipara show and rupture of membranes may occurs
now is when analgesic should be administered.
c) Transition phase:
dilation 8-10 cm
contractions peak every 2-3 minutes, lasting 60-90 seconds
if not done already, membranes will rupture at 10 cm as a rule
show will be present, last of mucous plug from cervix released
cervix now effaced and obliterated
primary need here is pain control!!

Second stage:
the period from full dilation and cervical effacement to birth
contractions change to urge to push
fetus in pelvis and crowning
Third Stage:
After infant is born, the uterus can be palpated as firm round mass , after a few minutes of rest, uterine contractions begin
again, and uterus assumes a disc shape until placenta has separated, approx 5 minutes after birth.
a) Placental Separation
occurs automatically as the uterus resumes contractions
active bleeding on maternal surface of the placenta starts, and helps to separate the placentaby pushing it away from
attachment site.
The following signs show placenta has loosened and is ready to deliver
1) lengthening of umbilical cord
2) sudden gush of vag. blood
3) change in shape of uterus
Normal blood loss is 300-500 mL's

b) Placental Expulsion
placenta delivered by bearing down or gently pressing on fundus
Never put Pressure on uterus in noncontracted state, l/t hemorrhage
Assessment of laboring mom
1) Fetal Heart Rate: (normal between 110-160)
2) Meconium staining: fetal hypoxia?, normal in breech presentation. Report immediately
3) fetal hyperactivity: Hypoxia?

4) fetal acidosis
5) Mom's high/low BP
6) Mom's abnormal pulse: hemorrhage
7) inadequate or long contractions
8) mom has full bladder: stops baby's head from decending, may injure bladder
9) Leopold's maneuver : palpating abdomen to determine fetal position and presentation
10) Vaginal exam
11) Assessments of contractions: Length, Intensity, Frequency
Para The number of pregnancies that reached viability, regardless of whether the infants Were born alive or not.
Gravida A women who is or has been pregnant
Primigravida A women who is pregnant for the first time
Primipara A women who has given birth to one child past the age of viability
Multigravida A women who has been pregnant before
Multipara A women who has carried two or more pregnancies to viability
Nulligravida A women who has never been and is not currently pregnant
Oxytocin (pitocin)
-IM or IV to increase contractions and minimize bleeding
obtain baseline BP, as it causes hypertension, don't use on women with prior hypertension
can be continued upto 8 hours after birth to ensure contractions

Narcotics (IM/IV)

Common pain meds for labor

Lumbar epidural

demerol

marcaine

morphine

naropin

fentanyl

Can add morphine or fentanyl

Pudendal block
Local, eg. lidocaine

Assessment of New Mom

-puerperium or post-partal period is the 6 weeks after delivery
_assess for the taking in, taking hold and letting go phases.
immediately assess vitals, uterine fundal height, lochia characteristcs, urinary and bowle system,evidence of perineal
healing, physical activity.

Involution: is process where reproductive organs return to non-preg state.

First, area where placenta was seals off, then uterus reduced in size.
-The fundus of uterus immediately after birth is halfway between umbillicus and symphysis pubis.
One hour later it is at level with umbilicus, where it stays for 24 hours
from then on, it will decrease 1 cm (fingerbreath) per day
eg. For first day post-partal, it is palpated one cm below umbilicus, on day 2+ 2 cm below, and by the 9 th or 10th day, it is
withdrawn into the pelvis and can't be palpated,
Never palpate fundus without supporting lower segment
uterus of breastfeeding women contract faster due to oxytocin.
Assess after bladder is emptied. May be found slightly to the right d/t colon.
Afterpains are contractions after birth, are good, as uterine atony means no throbus have formed and therefor can lead to
hemorrhage.
May massage fundus until firm, or apply ice to perinium

-Lochia: consists of blood, WBC, bacteria, mucous, and part of placental wall.
For the 1st three days: lochia rubra= mostly blood
by 4th day: lochia serosa= more leukocytes, pink/brown 3-10 days, mucous

by 10th day: lochia alba= white, mucous, WBC, decreased flow, lasts 3-6 weeks.
Amount will vary among women. There should be no large clots and no offensive odor. It should be present for about 1-3
weeks and anything more then 1 soaked pad per hour should be investigated.
Breasts: Prevention/alleviate breast engorgement
-allow baby to suckle frequently (main treatment for tenderness/soreness)
-application of warm compresses or a warm shower
-good support bra
-cold compresses applied 3-4 times daily during engorgement
-analgesics, creams
Promote Breast Hygiene
-care should be directed at cleanliness and support
-wash breasts daily with clear water and dry
-soap should be avoided because it causes dryness and cracked nipples
-use of gauze or bra pads to absorb colostrums/milk
-encourage mother to continue with self- breast exams monthlysecreting colostrum from
-on day three, breast become full of milk from response of fall in estrogen and progesterone levels
Episiotomy
: turn women into sims position with back towards you and assess perineum, observe for eccymosis, hematome, erythema,
edema, intactness, drainage, bleeding
-episiotomy usually 1-2 inches long.
-may have soothing cream, sotx bath witch hazel preparations
Pre-op Assessment of C-section Mom
-interference with self-esteem: scars
-stress response: increased HR, bronchial dilation, increased Blood glucose, increased BP
-Women's knowledge of procedure (ie. Length of stay, catheter, IV)
-Operative risk , age, fear
-Poor nutritional status: Obesity= increased infection, dehiscence, poor heart, difficulty turning
-Teaching: deep breathing, incentive spirometry, turning, ambulation
-Informed consent?
-pre-op hygiene, enema, skin prep, admin meds, anesthetic.
C-section
-2 types of incision- classic:vertical, from umbillicus to pubis, and Low-segment incision: horizontally, most common, also
called bikini, cut thru non-active part of uterus, it is less likely to rupture in later births, therefor mom can delivder
vaginally.
Retractors then spread apart incision, oxytocin given.
*** Mrs. C has just undergone a C-section, and she and her baby have just entered the recovery room. The nurses initial
action is to inspect her dressing and lochia (not newborn assessment, as it would have already been done)
Complications of mother Post-delivery
-Post partum hemorrhage: Four main causes:
1) uterine atony: if uterus suddenly relaxes, there will be sudden gush of blood, weigh pads, palpate fundus frequently, check
signs of shock, immediately massage fundus, infuse oxytocin,
2) Lacerations: 1st to 4th degree
3) Retained placental fragments: keeps uterus from fully contracting
4) Disseminated intravascular coagulation: deficiency in clotting due to vascular injury
-perineal hematoma: collection of blood in SC tissue of perineum, occurs with spontaneous births or perineal varicosities
Puerperal infection: increased risk with ruptured membrane over 24 hrs prior to birth, placental fragments, postpartal

hemorrhage, anemia, prolonger labor, internal fetal heart monitoring.

Common infections are, strep B, E Coli, Staphylococcyl.
Wipe front to back, Give full course of antibiotics. May have difficient breastmilk.
Edometritis: infection of lining of uterus,
peritonitis: usually extension of peritoneal cavity, major cause of death of mothers. Spreads thru lymphatic system.
Assess for rigid abdomen, fever, rapid pulse, vomiting. Often accompanies by paralytic ileus (needs NG tube), IV fluids
thrombophlebitis: inflammation of the lining of blood vessel with formation of clots. Usually extension of endometrial
infection. Caused by increased fibrogen levels, dialation of lower extremity viens due to pressure of fetal head, inactivity.
Can have DVT or SVD (superficial vien disease. Increased incidence with obesity, varicose viens, Hx of clots, women
over 30. Wear stockings.
Femoral thrombophlebitis: femoral, saphenous or popliteal viens involved. Decreases lower circulation. Positive homan's
sign
Mastitis: organism usually enters through cracked nipples. Breasts unilateral, red, swollen. Give antibiotic, cold
compress, support bra,
Urinary problems: Retention can be from bladder edema from pressure of birth, associated with use of anesthesia and
forceps. Always measure voiding after birth.

baby blues: 70% of all births, 1-10 days after birth. Due to anticlimax, change in hormones
post-partum depression: 10% of births. 1-12 months after birth.
Postpartal psychosis: 1-2%.
Care of Newborn
BATHING

The room should be warm to prevent chilling. Bathwater should be around 98 degrees or warm to the elbow or wrist. If
soap is used, it should be mild and without a hexachlorophone base. Bathing should be done before feeding to prevent
vomiting and possible aspiration. Supplies needed are: basin of water, mild soap, washcloth and towel, clean diaper. Never
leave baby unattended. Bath from cleanest to dirtiest. Wipe eyes with clear water from the inner canthus outward using a
clean portion of the washcloth for each eye to prevent spread of infection. Wash face with clear water to avoid irritation.
Wash hair daily with the bath: soap hair in crib with baby lying flat. Then hold baby in one arm over basin like a football,
rinse hair thoroughly and dry well to prevent chill. Each area of baby should be rinsed well and dried. Wash area around
cord taking care not to soak the cord. A wet cord remains in place longer than a dry one and allows for bacteria growth.
Wash penis gently, and do not force the foreskin back or constriction may result. Wash the vulva in females from front to
back to prevent contamination. Avoid baby powders as they can cause respiratory irritation. If babys skin is dry add oil to
the bath water.
CORD CARE
Within a few minutes after the cord is cut, assess cord for bleeding. -Cord Care: Has to have one vein and two arteries. Make
sure clamp is secure. Black by 2nd -3rd day. Breaks off after 6-10th day. Should have no smell, bleeding. Apply antibiotic to
reduce infection. Cord usually falls off around the 7-10th day of life. Until then the baby should be sponged bathed rather
then submerged in a tub. Be certain that the diaper is folded below the level of the cord so when the diaper becomes wet the
cord does not. Keep the cord as dry as possible until it falls off. The use of creams or lotions should be avoided because
they slow the drying process and invite infection. You can use rubbing alcohol 1-2 times daily to hasten dryness. After the
cord falls off a small pink granulating area about may remain. This should be left clean and dry until it heals.
MAIN PRINCIPLAS OF BREAST FEEDING
-Ensure mother is relaxed and is in a comfortable position (this allows for a good let-down reflex.)
-Its important that the baby opens their mouths wide enough so they can grasp the nipple and areola. This gives them an
effective sucking action and helps to empty the collecting ducts completely. It also prevents the nipples from becoming
cracked and sore. The use of the rooting reflex is effective in encouraging the baby to grasp the nipple.
-Advise mother to feed baby on one breast for about 10 min. and then switch to the other side increasing this time with
subsequent feedings.
-baby should be placed first at the breast at which they fed last in the previous feeding, this ensures that each breast is
completely emptied.
-Instruct mother on how to break suction to remove infant-have her insert her finger in the corner of the babys mouth or pull
down on the chin.

-Keep baby awake to ensure they are getting enough nutrition by tickling their feet or rubbing their arms/chest. This also
helps to produce more milk because it is produced by demand and prevent mastitis.
-Burp baby between breast changes and after the feeding.
- Feed baby when hungry, and count # of wet diapers (6-8/day)
Newborn Assessment
-neonatal period is the first 28 days
-APGAR: at 1 and 5 minutes after birth, heart rate, color, respiratory effort, muscle tone, reflex irritability are rated 0, 1, or 2
and then rated out of 10. Under 4 is dangerous, 7-10 is good.
-Heart Rate: starts are 180 then lowers and stabilizes at 120-140, often irregular
-blood pressure starts at 80/46, then rises to 100/50
-Respirations: 30-60, short periods of apnea normal, as is crying
-Weight: 2.5-3.4 kg, (3500g) losses 5-10% after birth, then should gain 6-8 oz per week.
-length: 46-54 cm
-head circumference: 34-35 cm
-chest circumference is 2 cm less the head
-temperature: 37.2 then lowers to 37.0. Can lower due to loss of heat from convection, radiation, conduction, and evaporation
. They have little insulation and don't shiver to produce heat. They have brown fat, not SC fat.
needs to pass menonium ( mucous, vernix, lanugo, hormones, carbs) by 24-48 hours. Then passes transitional stool, then
3-4 normal stools, . Newborn under lights for jaundice have bright geen stools.
Voids 12-24 hours after birth, about 15 mls.
Breastfeeding/ nutrition:
-baby should sleep between feedings
-shouldn't lose more than 10% of birth weight
-Voids 6-8 times a day, and 2-3 bm's a day
-Usually feeds q2-4 hours. And will usually eventually establish a schedule.
mom produces colostrum for the first 3-4 days. High in protein, low in fat and sugar, easy to digest.
Transitional breast milk on the 2nd-4th day, and true breast milk by day 10.
- Practicing breast massage helps bring milk forward, NO soap, Open infants mouth Wide, place infant on breast on which
they last fed to make sure it fully empties as this leads to further milk production, wash hands first, brush baby's cheek, place
warm packs on breasts,
- DON'T offer bottles until after 6 weeks.
- if child is under three months, and is constipated, teach mom to drink one tbsp of boiled water between feedings.
Introduce pureed foods one at a time, usually at 4-7 day intervals. Start with cereals and pureed fruits
Advantages of breastfeeding: prevents breast CA, release of oxytocin aids in uterine involution, contains
immunoglobulin A, other antibacterial proteins, WBC's , high in lactose (easily digested sugar), amino acids, linolic acid,
better formed dental arch.

Contraindications of breastfeeding: infant that cannot digest lactose, herpes lesions on nipples, , mother on nutrientrestricted diet, mother on meds that transfer in milk, breast CA, maternal exposure to radioactive compounds, Hep B,
HIV.
Reflexes:
*limpness or lack of muscular response can be from narcosis, shock, or cerebral injury. Occasional twitching or flailing
d/t immaturity of NS.
Blink:use sudden light
rooting:head turns when cheek or corner of mouth is brushed
sucking:suckling motion when mouth touched
swallowing: same as adult
extrusion: will extrude any substance placed on anterior tongue, disappears at four months
palmar grasp: grasp object placed on palm
plantar grasp: toes grasp at object placed on sole of foot
step-in-place: dissapears at 3 months
placing: if legs touch edge of table, they will kick and try to step up

tonic neck: head turns to one side when lying down. Arm and leg on side which head is turned extend, and opposite arm
and leg contract
moro:startling newborn with loud noise, or holding on their back and allowing head to drop back. Arms should abduct
and extend, fingers go in 'c' shape, legs pull up to chest.
Babinski: foot goes to inverted j, and toes fan out.
Magnet: if pressure is applied to sole, while lying supine, they pull their foot back
crossed extension: if one sloe if irritated, the other leg pulls up and away.
trunk incurvation: when lying prone, and a finger touches paravertabral area, they will flex trunk and swing pelvis
towards the touch
landau: newborn held prone on one arm, they should have some muscle tone, but not be able to hold up head
deep tendon: patellar reflex..

Newborn Complications
-Hyperbilirubinemia: Occurs in the 2nd -3rd day in about fifty percent on new baby's as a result of the RBC breakdown,
leads to jaundice. Watch newborns with lots of bruising from birth, may lead to hemorrhage. Tx is phototherapy or exchange
transfusion.
- Hemorrhagic disease: deficiency in Vitamin K. All babies get Vit K at birth.
-Anemia: due to: 1) excessive blood loss when cord was cut 2) inadequate blood flow from cord 3) fetal-maternal
transfusion 4) mom's poor nutrition 5) blood incomparability
-Mucousy Baby: ineffective airway clearance.
-Respiratory Distress Syndrome: common in preterm infants due to lack of surfactant in the alveoli. Tx is artificial
surfactant by ET tube and ventilator.
-Small gestational age: birth weight below the 10th percentile. Have difficulty maintaining body warmth d/t low birth
stores. May develop hypoglycemia.
-Preterm Infant: born before 37 weeks. Have respiratory, problems, anemia, jaundice, persistent patent ductus arteriosis,
intercranial hemorrhage. Low birth weight is anywhere from 500-2500 g.
-Postterm infant: past 42 weeks. Problems with meconium aspirations, hypoglucemia, respirations, temp regulation.
-Transient tachypnea: is temporary condition caused by slow absorption of lung fluid.
-meconium aspiration syndrome: when infant inhales meconium-stained amniotic fliud during birth. Leads to airway
spasm or pneumonia. May need suctioning and O2, or antibiotic.
PEDIATRICS/FAMILY CENTRED CARE
Factor influencing growth and development
1) Genetics: Gender, Race, Nationality,Health, Intelligence
2) Environment: socioeconomic level, parent-child relationship, ordinal position in family, health, nutrition
3) Temperament: temperament is the usual reaction pattern of an individual, or their characteristic manner of thinking,
behaving, or reacting to stimuli in the environment. It is an inborn characteristic

FREUD

ERIKSON

Psychosexual Stage

Developmental Task

Infant

Oral Stage: child uses mouth and

tongue to explore the world

To form a sense of trust versus mistrust. Child learns o love and be

loved

Toddler

Anal Stage: Learns to control

urination and BM's

To form a sense of autonomy versus shame. Child learns to be

independent

FREUD

ERIKSON

Psychosexual Stage

Developmental Task

Preschooler

Phallic Stage: Learns sexual

identity thru awareness of genital
area

To form a sense of initiative versus guilt. Child learns to do things

(basic problem solving) and that doing things is desirable

School-age
child

Latent Stage: Personality

development appears nonactive/dormant

To form a sense of industry versus inferiority. Child learns how to

do things well

Adolescent

Genital Stage: Developes sexual

maturity and learns to establish
sexual satisfaction with partner.

To form a sense of identity versus role confusion. Adolescents learn

who they are and what kind of person they will be by adjusting to a
new body image, seeking emancipation from parents, choosing a
vocation, and determining a value system.

Young Adult

Achieving a sense of intimacy versus isolation. Making friendships

and relationships.

Middle Age

Establish a sense of generativity versus stagnantion. Extend

concern from themselves to families/community/world.

* the #1 health risk for adolescence is unintentional injuries

*2 priorities of IV therapy in children: secure tubing, monitor I & O's, right IV solution, verify rate, monitor insertion site,
family invovlment
-to maintain the site: use transparent drsg, cover the site, anchor tubing, observe for inflammation, infiltration.
Observe frequently
nonverbal communication stratagies to use with kids:
position, (turn towards her, at same height)
posture, (open, relaxed,)
facial expression, (smiling,)
movements, (nodding, mirroring)
alternate communication stratagies (play, pictures, puppests)
pitch,volume, rate, emphasis)
Play
initiated by parent
important throughout childood
promotes physical development
Erikson: stresses importance of culture and society. Main tenets is that one's social view of themselve is more influential
than than instinctual drives.

Stage of Development
Sensorimotor

Age

Example

1-24 months 1 mo, Neonatal reflex: behavior only reflexive

1-4 mo, Primary circular reaction: hand-eye-mouth coordination
4-8 mo, Secondary circular reaction: learns to initiate, recognize, and repeat
pleasurable things
8-12 mo, Coordination of secondary reactions: plans activities to attain
specific goals. Experiences separation anxiety
12-18 mo, tertiary circular reaction: discovers new properties of objects. Has
space/time perception and permanence.
18-24, invention of new means thru mental combinations: Uses memory to
imitate. Can solve basic problems

Preoperational Thought

2-7 Years

-Thought becomes symbolic

-Comprehends abstract, but thinking is literal and concrete.
-Egocentric
-Static thinking
-Concept of time is now

Concrete Operational
Thought

7-12 Years

- systemic reasoning
-uses memory
-Classification
-Aware of reversibility
-understands conservation

Formal Operational
Thought

12 Years

- can solve hypothetical problems with scientific reasoning,

-understands past,present, future

Principles of Growth and Development

1) Growth and development and continuous processes from conception until death.
2) G & D proceed in an orderly sequence
3) Different children pass through the predictable stages at different rates
4) All body systems do not develop at the same rated
5) Development is cephalocaudal (head to toe)
6) Development proceeds from proximal to distal body parts
7) Development proceeds from gross to refines skills
8) There is an optimum time for initiation of experiences or learning
9) Neonatal reflexes must be lost before development can proceed.
10)
A great deal of skill and behavior is learned by practice.
1)
2)
3)
4)
5)

Key Nursing points for caring for a child in the hospital:

Don't tell of a hospitalization too far in advance. Tell them as many days prior to a procedure as their age in years, if
under 7.
Books about hospitalization are helpful.
Provide continuity of care. (primary nurse)
Provide opportunities for parents to do care
Maintain bed as safe area

6) Help child to maintain control

7) Set limits of behavior.
1)
2)
3)
4)
5)
6)
7)
8)

MedicationsKnow child currant weight and height, as well as developmental stage so the route is appropriate.
Know their past experiences taking meds
Drugs are metabolized faster in children, therefor must be given more frequently
Liver isn't fully developed in newborns, therefor distribution and metabolism is affected.
Kidneysnot mature intil 12 months, so excretion is limited
Adverse reactions are exaggerated d/t immature liver and kidney's
Doses based on body surface area usually.
Always double check dose in book
-

three early manifestation of intracranial pressure in children:

1. headache 2. Nausea 3. vomiting 4.change in LOC 5.siezure 6.irritability 7. double/blurred vision

3 signs of bleeding: 1. melena: bloody stool 2. petechiae: Pinpoint red spots on the skin3. Ecchymosis: skin
discoloration caused by the escape of blood in the tissues from ruptured blood vessels

Referrals to parents of children who have died: social worker, spiritual edvisor, bereavement program, local support
groups

Common Chromosomal disorders:

-Down's (trisomy 21), 1 in 800 births, most common, esp. women over 35, or men over 55, eyelids have extra fold, iris has
white flecks, eyes turned down, small oral cavity, tongue protruding, flat back of head, extra fat at base of neck, low-set ears,
poor muscle tone, short fingers, simian line in palm,
-Klinefelter Syndrome (males with XXY), female characteristics.
Asthma
defined as a chronic inflammatory disorder of the airways
affects ~10 20% school-age children
usually disappears by late adolescence
marked by re-current attacks of dyspnea, with wheezing d/t spasmodic constriction of the bronchi
attacks vary from occasional periods of wheezing & slight dyspnea to severe attacks that almost cause suffocation
attacks which last for several days is called STATUS ASTHMATICUS this is a medical emergency*******
can be fatal!
CAUSES:
- allergy to antigens; pollen, dust, smoke, automobile exhaust & animal dander
- can be secondary to chronic or recurrent infections of bronchi, sinuses, or tonsils & adenoids (hypersensitivity to
bacteria or viruses causing infection)
- family Hx ( different types of allergies)
S/S:
- dyspnea & wheezing type respirations
- chest tightness, tachycardia, tachypnea, anxiety, cyanosis, cough
- sitting positions & leaning forward to use all accessory muscles of respiration
- skin pale & moist with perspiration, in severe attack cyanosis of lips & nail beds
- early in attack cough is dry progresses becomes thick, productive, tenacious, mucoid sputum
- Arterial blood gases will reveal: respiratory acidosis, decreased pH, increased CO2, decreased O2
TX:
-

- supply O2
- place in high fowlers
- remain with client
- establigh IV
- encourage slow, deep breathing
- stay calm
- avoid triggers (extrinsic factors, pollen etc.), stress
- no cure for asthma
- bronchodilators
- expectorants may also be prescribed
Pt. CARE:
- encourage deep breathing & fluids
- place in high fowlers,
- stay calm during attack
- relaxation techniques (explore)
- lots of reassurance when dealing with younger children with appropriate explanations
Dehydration in babies and small children

Babies and small children have an increased risk of dehydration because:

A large proportion of their bodies consists of water.

Children have a high metabolic rate, so their bodies use more water.

A child's kidneys are not as efficient and do not conserve water as well as an adult's.

They have an immature immune system, which increases the risk of illnesses that cause vomiting and
diarrhea.

Children often will not drink or eat when they are not feeling well.

They depend on their caregivers to provide them with food and fluids.

Watch babies, small children, and older adults closely for the early signs of dehydration any time they have illnesses that
cause high fever, vomiting, or diarrhea. The early symptoms of dehydration are:

A dry mouth and sticky saliva.

Reduced urine output with dark yellow urine.

*Lab tests ordered: CBC , lytes, kidney function tst, urine spec. gravity, urine osmolality, stools
Anorexia
- refusal to maintain minimally normal body wt. because of disturbance inn perception of size of appearance of body
- can cause delayed psychosexual development
- individuals may look younger than age d/t starved appearance
- dehydration & acidosis can occur from starvation
CHARACTERIZED BY:
- BMI under 17.5 or less than 85% expected body wt.
- Intense fear of gaining wt. or becoming fat despite being grossly under wt.
- Severely distorted body image
- Refusal to acknowledge seriousness of wt. loss
- Amenorrhea (in girls)
TX:
- behavior modification: earning privileges for acceptable behavior and losing privileges
- establish trust & effective communication
- medications/anti depressants
- identifying of emotional triggers
- self monitoring (awareness training)
- education about normal nutritional needs
Cystic fibrosis
-hereditary, chronic disease characterized by abnormal secretions of the exocrine glands.
-Adults with CF are barrel-chested, skinny, malnourished clubbed fingers, and receive oral pancreatic enzymes and vitamins.
-Current Tx is hospitalization with thorough pulmonary hygiene, IV antibiotics, and antifungals, as well as postural
drainage using a range of positions to drain all segments of the lungs, and administration of pancreatic enzymes in
morning and bedtime. Must encourage coughing
Leukemia
LEUKEMIA (ACUTE LYMPHOCYTIC LEUKEMIA (ALL) )
- the distorted & uncontrolled proliferation of white blood cells (lymphocytes)
- most common CA in children
- malignant cell involved is lymphoblast (an immature lymphocyte)
- with rapid proliferation of lymphocytes, production of RBCs & platelets falls, & invasion of body organs by the
increased WBC element begins
- highest incidence of ALL in kids btw. ages 2 & 6 and is slightly higher in boys than girls
- cause is unknown
S/S:
- pallor, low grade fever and lethargy
- may have PETECHIA pinpoint, macular, purplish-red spots caused by intradermal or submucous hemorrhage
- bleeding from oral mucous membranes may occur
- bruise easily
- see page 1646 in Pilliteri for more detail & info.
TX:
- 95% of children will have first remission
- leukemia is classified to define subgroups of cells & to predict the usual response to treatment
- chemotherapeutic agents
- bone marrow transplant after a remission is achieved by chemo
** monitor for melena, petechia, and ecchymosis, as they are signs of bleeding
** if neutrophils or temp rise too high, the pt. Should be put in reverse isolation
Burns
-burns to hands and feet are increased risk fro secondary infection....give tetanus or booster.
-In adults, the rule of nine estimates extent of burn: each arm and leg are 9%, head and neck is 9%, / This does NOT apply
to children, as their body surfaces are different.

-Depth of burn: Partial-thickness burns are 1st and 2nd degree burns. First degree burns are top layer of skin (superficial
epidermis), second degree are the entire epidermis.
-A third degree burn is a full-thickness burn. It involves both layers of skin, fat, muscle, bone etc. They are not painful as
nerves, sweat glands, and hair is burned.
Possible complications: Pain, deficient fluid volume r/t fluid shifts, ineffective tissue perfusion, impaired urinary
elimination, imbalanced nutrition, infection
three methods of promoting emotional support in children with disturbed body image: peer contact, discuss with family
and child, aid to cover burn, referral for councelling
Depression
- incidence 1 3% before puberty & 3 6% in adolescents
S/S:
- loss of interest or pleasure
- significant wt. loss
- depressed mood
- insomnia
- psychomotor agitation
- diminished concentration
- feelings of worthlessness or excessive or inappropriate guilt
- recurrent thoughts of death & suicide ideation
- exists for 2 weeks or more
TX:
-

counseling/therapy
medication/anti depressants
family support

abuse
physical signs of sexual abuse in children:
genital pain/iritation, injury,
undrclothing torn, blood etc
discharge
STD's
difficulty walking/sitting
problems with urination
presence of spermicidepregnancy
if abuse if suspected, nurse mustcontact provincial child protection agency (social services, child welfare, police)
attention/hyperactivity disorder
-ADHD is inattention, hyperactivity, or impulsiveness revealed before age 7, usually boys.
-Tx is environmental, family support, and meds such as ritalin.
S/S:
TX:
-

TONSILLITIS/TONSILLECTOMYT
inflammation & infection of palatine tonsils
children drool swallowing is too painful
high fever
lethargy
tonsillar tissue appears bright red, & so enlarged that tonsil tissue meet in the mid-line
pus can be detected on or expelled from the crypts of the tonsils
mouth breathing
if cause bacterial antibiotics
tonsillectomy/adenoidectomy depends on symptoms
Sx done when organs are NOT infected, to prevent spread of pathogens

appendicitis/ appendectomy
-appendix is pouch on end of cecum, may be inflammed after other infection.
-pain is a late symptom of appendicitis, first is anorexia, N&V, pain is 1 st diffuse, and in RLQ or 1/3 way between umbillicus
and superior iliac crest (McBurney's point)
-Look for rebound tenderness, Leukocytosis, (increased WBC)

cleft lip/palate repair

congenital fissure, or split of the lip or the roof of the mouth (palate)
one or the other occurs in ~ 1 in 1000 births
sometimes associated with clubfoot or other anatomic defects
no connection with mental retardation
results from failure of the two sides of the face to unite properly at early stageof prenatal development
defect may be minor involving only outer lip of mouth or more severe involving entire upper portion of mouth
infants unable to suckle properly opening prevents suction, feeding must be done by other means
food may get into nose cause difficulty in chewing & swallowing , later it will hinder speech

TX:
- Sx followed by measures to improve speech
- usually treatment is initiated ~ 18 months
Pt. CARE:
- main concern is adequate nutrition pre-op & post-op
- prevention of resp. infections
- frequent mouth care
- lots of reassurance to encourage self-esteem
- speech training also encouraged
Measles
incubation: 10-12 days
communicability: 5th day of incubation to first few days of rash
transmission: direct or indirect contact with droplets, contracting disease offers lasting immunity
different from German measles, which last 3 days. These last 7 days
-have enlarged lymph nodes, fever, malaise, rhinitis, sore throat, conjunctivitis, photophobia, cough, and Koplik's spots
( small, irregular red spots with blue/white centre) . They appear on gums, then rach spreads around hairline, ears,
forehead, neck ect.
Tx= comfort
Chicken Pox
-AKA: Varicella-zoster virus
-incubation: 10-21 days (the time between exposure to the virus, and the appearance of the first symptoms)
-communicable: 1 day before rash to 6 days after appearance
-Transmission: direct/indirect contact of saliva or vesicles
May be re-activated later as herpes zoster
Low-grade fever, malaise, rash,

Immunizations
2-18 months: Diphtheria, Pertussis, Tetanus, Polio, Haemophilius Influenzae B
* Booster for tetnus and diptheria q10 years
12-18 months: Measles, mumps, rubella
12-18 months: Meningococcal C and pneumococcal conjugate
12 months: Varicella
2 months or middle school : Hep B
65+: Pneumococcal polysaccharide
6 months+: influenza q yearly
2 reasons not to proceed with vaccinations: 1. prior reaction/anaphylaxis 2. encephalopathy 3. immunosippressant therapy,

Side effects: pain at site,fever, irritability, sleepiness, loss of appitite, vommiting, redness, swelling,

Site most perferable for immunizations with kids under one year: lateral thigh muscle
MENTAL HEALTH
***During a psychiatric emergency a nurse should: Reduce environmental stimuli, establish rapport with client/family,
assess safety, prioritize needs, identify available resources
*** determine stressful events that occur at times hallucinations occur
***if in unsafe situation, 1) leave room 2) call for assistance
*** Nurse may need to involve police, seek court order from judge, arrange for psych consult, or contact mental health crisis
teams in order to get pt. To hospital if they refuse.
SCHIZOPHRENIA
a mental disorder characterized by disordered thoughts, hallucinations and delusions. The client loses rational thought and/or
ability to use rational mental processes especially when client is experiencing an acute episode usually due to going off
medications.
Symptoms are considered Positive & Negative
Positive: behaviors that clearly display pathology
Negative: represent a change from the individuals prior personality & leads to social isolation and anhedonia
There are 2 main approaches to treatment: psychosocial and pharmacological (neuroleptics i.e. clozapine & olanzapine) &
(Benzodiazepines i.e. diazepam & clonazepam) (most common side effect: Dystonia)
Sings of an active Hallucination: Pt.s verbal report, appears to be listening to someone else, responding to sensory stimuli,
seems distracted, reports from others
MOOD DISORDERS
Mood disorders are most often characterized by feelings of depression
The most common MD is: Major depressive disorder
Others include: dysthmia (significant sadness most days for at least 2 yrs) & Bipolar
DEPRESSION
: The state wherein an individual experiences a profound sadness; the intense feeling of a depressed, down mood.
-if a depressed pt comes into emerg, the two most important factors the triage nurse must assess are: suicide plan, and risk of
suicide
A depressed person loses interest in activities that were previously enjoyable, as well as a loss of appetite or weight, sleep
disturbance, fatigue, feelings of worthlessness, trouble with concentration, recurrent thoughts of death or suicide
Most important nursing intervention: establish trusting relationship with client
Common meds: tricyclic & related antidepressants, SSRIs, MAO inhibitors
*** symptoms of major depressive disorder: depressed for over 2 weeks, anhedonia, social withdrawal,
appetite changes, change in sleep patterns, decreased libido, impaired cognitive function
recurrent thoughts of death, feelings of worthlessness
*** three risk factors for suicide: verbalized intent to commit suicide, having a plan for committing suicide, preoccupation
with death/dying, current depression, available means, lack of social support, drug/alcohol use, saying good-bye, gender

(male), adolescent or over 60, life stressors, previous attampts

BIPOLAR DISORDER
: Characterized by episodes of excitement and racing thoughts, often, but not always alternating with episodes of depression.
Goal of treatment: to get client to a place where they are more even keel
PERSONALITY DISORDERS
: An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individuals
culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress
or impairment.
PD is usually a result of a chaotic and violent family life
Common types of PD:
Borderline PD patterns of unstable personal relationships and self-image, efforts to avoid being abandoned and impulsive
actions
Narcissistic PD self-centeredness & and inflated self esteem, overestimation of abilities, feeling superior to others and
demand admiration
Antisocial PD violent, impulsive, dishonest, careless & irresponsible
Treatments: psychotherapy & cognitive-behavioral therapy
Nurses must recognize:
- these disorders in clients
- know the difficulty in establishing a nurse-client relationship
- disagreements among team members regarding client
- personal reluctance to care for client
- difficulty in reaching treatment goals
(these may be warning signs a PD exists)
PHOBIAS
: A persistent fear of a specific object or situation
They are categorized as:
Social Phobia (aka: social anxiety disorder): severe anxiety when under social stress
Specific Phobia: fear of things (i.e. planes, high places, animals, seeing blood)
OBSESSIVE COMPULSIVE DISORDER
Obsessions: are recurrent thoughts, images or impulses that are experienced as intrusive and inappropriate and that cause
marked anxiety or distress
Common obsessions fear of self-contamination, fear of forgetting to do something
Compulsions: are repetitive behaviors with the goal to prevent or reduce anxiety or distress
ADDICTION
Goals of nursing care:
- prevent alcohol withdrawal delirium through administration of drugs
- correct fluid & electrolyte imbalances
- assess pt for associated medical conditions (i.e. liver damage, pancreatitis, altered blood glucose levels)
Treatment: drug detoxification followed by counseling, group support and medication
In overdoses, anticipate: respiratory arrest, heart attack, cardiac arrhythmia, siezure
PANIC DISORDER (an anxiety disorder)
: Discrete episodes of intense anxiety that begin abruptly and reach a peak within about 10 minutes

Symptoms: palpitations, sweating, trembling, SOB, sensation of choking, chest pain, nausea, dizziness, fear of loosing
control, fear of dying, sense of altered reality
DEMENTIA
: a broad diagnosis that includes multiple physical disorders characterized by alterations in memory, abstract thinking,
judgment, and perception. It often results in a progressive decline in intellectual functioning and decreased activity to
perform daily activities. Poor judgment and insight
Gradual onset over months or years.
Nursing Care: maximize quality of life
Outcomes should be determined by the extent to which the impairment may be arrested or reversed
Characteristics: an impairment of memory and at least one of the following aphasia (difficulty recalling words), apraxia,
agnosia or a disturbance must be significant enough to cause a disturbance in everyday functioning.
ALZHEMIERS
: a progressive disorder characterized by stages of increasing impairment and dependency
Approximately 60% of dementias is a result of Alzheimers
Early signs of the disease (although memory impairment is the key diagnostic criteria) are often of the behavioral type, i.e.
suspiciousness, paranoia, irritability, aggression or angry outbursts, hoarding, withdrawal
SUICIDE
Questions to ask:
- Do they have a plan?
- Are they able to carry it out?
- Are they rational?
Pay attention to:
- Verbal Cues
- Behavioral Cues: previous attempts, buying a gun, stockpiling pills, giving away possessions, loss of interest,
making/changing a will, funeral plans, suspicious behavior
- Situational Cues: death of spouse/child/friend, death of pet, major move, diagnosis of terminal illness, retirement,
flare-up with friend/family member
Nursing Care:
- encourage hospitalization
- restrict access
- establish a suicide contract or agreement
- have one-on one contact at all times
- decrease social isolation
- decrease psychological symptoms
ECT (Electro Convulsive Therapy)
: A procedure in which clients are treated with pulses of electrical energy sufficient to cause a brief convulsion or seizure.
The passage of an electrical stimulus to the brain to produce a seizure.
Particularly helpful in the elderly
Its carried out under anesthesia
Most common side effect: temporary or permanent memory loss
ECT is used primarily to treat major depressive episodes where other treatments have failed
Nursing Care:
- Consent signed
- NPO midnight

Post-op: monitor for resp distress, assess VS, observe level of confusion, encourage rest
Patho/ Common Diseases & Illnesses

Rheumatoid arthritis:
for comfort, apply splints in dorsiflexion, Use miost, warm compresses for 20 mins, and have assistive devices installed
Have family help reform passive ROM's in active ROM's are painful
Diabetes Mellitus
There are three types of diabetes: type 1, type 2, and gestational diabetes.
Type 1 diabetes some or all of the insulin-producing cells of the pancreas are destroyed, leaving the patient with little or
no naturally produced insulin. Only about 5- 10 % of people with diabetes have type 1.
Type 1 diabetes can develop at any age; however, it usually develops in children and young adults, which is why it was
formerly called juvenile diabetes. It has also been called insulin-dependent diabetes mellitus (IDDM) because insulin
must be taken daily
.
Type 2 diabetes: most common form of diabetes the pancreas makes insulin but the cells in the body do not respond to it.
(NIDDM)
Gestational diabetescertain pregnancy-related hormones make the body resistant to insulin.
Diabetic complications

Eye damage (retinopathy) In this disorder, tiny blood vessels at the back of the eye are damaged by high blood
sugar.

Nerve damage (neuropathy) High blood sugar can damage nerves, leading to pain or numbness of the affected
body part. Damage to nerves in the feet, legs and hands (peripheral neuropathy) is most common.

Foot problems Sores and blisters commonly occur on the feet of people with diabetes. If peripheral neuropathy
causes numbness, a sore may not be noticed and it can become infected. Blood circulation can be poor, leading to
slow healing. Left untreated, a simple sore can lead to gangrene (the death of soft tissue due to lack of blood flow),
and sometimes the leg or a portion of it may need to be removed surgically (amputated).

Kidney disease (nephropathy) High blood sugar can damage the kidneys. If blood sugar remains high, it can
lead to kidney failure.

Heart and artery disease (atherosclerosis deposits of fatty substances, cholesterol, cellular waste products,
calcium and other substances build up in the inner lining of an artery. This buildup is called plaque) Heart and
blood vessel problems can result from high blood sugar. People with type 1 diabetes are more likely to have heart
disease, strokes and problems related to poor circulation.

Diabetic ketoacidosis This occurs when acidic substances called ketones are made by the liver as a substitute
energy fuel instead of glucose. Symptoms include nausea and vomiting, abdominal pain, fatigue, lethargy and,
eventually coma and death. (assoc. with hyperglycemia) Symptoms of hyperglycemia frequent urination, thirst,
weakness and fatigue.

Hypoglycemia Low blood sugar, called hypoglycemia, can result if too much insulin is taken or not enough
carbohydrates are take in to balance the insulin. Symptoms include weakness, dizziness, trembling, sudden sweating,
headache, confusion, irritability, and blurry or double vision. Hypoglycemia can lead to coma if it is not corrected by
eating or drinking carbohydrates. Can be brought on by alcohol intake.

Diabetics should carry a source of concentrated glucose (glucose tabs, candy), as well as a source of complex carbs
and a protien which would follow (cracker and cheese) in case of hypoglycemia.

FYI: Diabetes Insipidus is a rare metabolic disease that is not related to diabetes mellitus. It is characterized by a
deficiency of the hormone vasopressin (anti-diuretic hormone. ADH), which is produced in the posterior lobe of the
pituitary gland. The lack of effect of this hormone on the kidney causes excretion of excessive quantities of very dilute (but
otherwise normal) urine. Excessive thirst and urination are the major symptoms of this disorder.Normal BS: 4-7
-Signs/symptoms of hypoglycemia
-Signs/symptoms of hyperglycemia
-How to respond :HyperHypo-Insulin Administration
-Short acting insulin:
Long acting Insulin:
Perforated Colon
symptoms of perforated colon: acute increase on abd. pain, rigid abdomen, absent (decreased bowel sounds
One life-threatening complication on perforated colon: Shock (hypovolemic or septic), peritonitis
Hypothyroidism
Hypothyroidism develops when the thyroid gland does not produce enough thyroid hormone, which regulates the way the
body uses energy. When levels of thyroid hormones are abnormally low, the body burns energy more slowly, and vital
functions, such as heartbeat and temperature regulation, slow down. The incidence of hypothyroidism tends to increase
with age, with older women at highest risk.

The most common cause of hypothyroidism in Canada is Hashimoto's thyroiditisdevelops when the immune system
produces antibodies that destroy thyroid tissue and thus reduce the thyroid's ability to produce thyroid hormone. Other causes
of hypothyroidism include the surgical removal of the thyroid gland, radioactive iodine therapy, and as a phase of thyroiditis
after childbirth.
CHF
Contrary to its name, congestive heart failure does not mean the heart has failed completely. It means the heart no longer is
able to meet the body's need for blood because it is pumping inefficiently. This inefficient pumping causes a backup of blood
in the veins leading to the heart. The body tries to compensate for the reduced pumping ability of your heart by:

Retaining salt and water by the kidneys to increase the amount of blood in your bloodstream. This causes the body's
tissues to swell. The swelling (edema) most commonly affects the legs, but it also can occur in the lungs, causing
breathing difficulty, and in other tissues and organs.

Increasing the heart rate

Increasing the size of your heartknown as cardiomegaly.

Congestive heart failure often is the end stage of another form of heart disease. Its many causes include: coronary artery
disease, hypertension, heart valve disorders (including rheumatic heart disease), congenital heart disorders, cardiomyopathy
(disease of the heart muscle), heart attack, cardiac arrhythmias (problems with the heart rate and/or rhythm), and toxic
exposures, including excessive intake of alcohol. Hyperthyroidism, diabetes and chronic lung disease also increase the risk of
congestive heart failure.

Treatment

The first treatment of congestive heart failure focuses on controlling the most severe (acute) symptoms. Bed rest is
prescribed to elevate the legs and discourage fluid accumulation in the feet and ankles

Diuretics are administered to remove excess body fluid by increasing urine output.

Digoxin (Lanoxin) to strengthen the heart's contractions

ACE inhibitors or angiotensin receptor blockers to expand blood vessels, decrease the resistance to blood flow, and
help to prevent water retention

Beta-blockers to improve blood flow

Anticoagulants also are prescribed to prevent blood clots, particularly if the patient requires a long period of bed
rest.
MI
A heart attack occurs when one of the heart's coronary arteries is blocked suddenly, usually by a tiny blood clot
(thrombus). The blood clot typically forms inside a coronary artery that already has been narrowed by atherosclerosis, a
condition in which fatty deposits (plaques) build up along the inside walls of blood vessels.

***Cor pulmonale: Cor pulmonale is failure of the right side of the heart caused by prolonged high blood pressure in the
pulmonary artery and right ventricle of the heart.
Symptoms
The most common symptom of a heart attack is severe angina, or chest pain, also described as discomfort, pressure,
squeezing, or heaviness. Many people also have at least one other symptom, such as:

Pain or discomfort that radiates to the back, jaw, throat, or arm.

Discomfort in the upper abdomen, often mistaken for heartburn.

Sweating, nausea, and vomiting.

Difficult breathing, palpitations, dizziness, and fainting.

Weakness, numbness, and anxiety.

Women, older adults, and people with diabetes are less likely to have chest pain during a heart attack and more likely to have
other symptoms.

Diagnosis

ECG can detect signs of insufficient blood flow, heart muscle damage, abnormal heartbeats, and other heart
problems.

Cardiac enzyme studies measure the levels the enzymes troponin ,creatine phosphokinase (CPK, CK), and lactate
dehydrogenase (lactic acid dehydrogenase or LDH) in the blood.

Treatment

O2

pain medication (usually morphine) for chest pain

beta-blockers to reduce the heart's demand for oxygen

nitroglycerin to temporarily increase blood flow to the heartif blood pressure is not too low

ACE (angiotensin-converting enzyme) inhibitors, which help the heart work more efficiently, primarily by
lowering blood pressure

Aspirin

Most heart attack patients also are given a prescription for a cholesterol-lowering medication.

Angina

Angina, also called angina pectoris, is discomfort or pain in the chest that happens when not enough oxygen-rich blood
reaches the muscle cells of the heart. Angina is not a disease, but a symptom of a more serious condition, usually
coronary artery disease, an illness in which the vessels that supply blood to the heart become narrow or blocked.
Coronary artery disease is usually caused by atherosclerosis, a condition in which fatty deposits (called plaque) build up
along the inside walls of blood vessels. Although angina most commonly affects males who are middle-aged or older, it
can occur in both sexes and in all age groups.

Stable angina Chest pain follows a specific pattern, occurring when someone engages in hard physical activity

or experiences extreme emotion. Other situations that bring on angina include smoking a cigarette or cigar, cold
weather, a large meal and straining in the bathroom. The pain usually goes away when the pattern or trigger ends.
Unstable angina Symptoms are less predictable and should prompt an immediate call to a health professional.

This chest pain occurs at rest, during sleep or very often with minimal exertion. The discomfort may last and be
intense.

Treatment

Lifestyle changes Changes include weight loss for obese patients, therapy to quit smoking, medications to lower

high cholesterol, a program of regular exercise to lower high blood pressure, and stress reduction techniques (for
example, meditation and biofeedback ).
Nitrates, including nitroglycerin Nitrates are vasodilators (medications that widen blood vessels). They increase

blood flow in the coronary arteries, and make it easier for the heart to pump blood to the rest of the body.

Beta-blockers, such as atenolol and metoprolol (Lopressor, Toprol-XL) These medications decrease the heart's

workload by slowing the heart rate and reducing the force of the heart's contractions, especially during exercise.
Calcium channel blockers, such as nifedipine (Adalat, Procardia), verapamil (Calan, Isoptin, Verelan), diltiazem

(Cardizem, Tiazac), amlodipine (Norvasc) These medications may help to improve the efficiency of heartmuscle function and may decrease the number and severity of episodes of chest pain.

Aspirin Because aspirin helps to prevent blood clots from forming inside narrowed coronary arteries, it can

reduce the risk of heart attacks in people who already have coronary artery disease.

Cardiac Arrest

A cardiac arrest is the cessation of normal circulation of the blood due to failure of the ventricles of the heart to contract
effectively during systole. The resulting lack of blood supply results in cell death from oxygen starvation. Cerebral
hypoxia, or lack of oxygen supply to the brain, causes victims to immediately lose consciousness and stop breathing.

RESPIRATORY
* best position for pt with chest tube= semi-fowlers, side-lying with head raised

Adventitious Breath sounds:

stridor: shrill, harsh sound- heard on inspiration in laryngeal obstructions

crackle (formally rale): explosive, "popping" sounds heard more commonly during inspiration imply either accumulation
of fluid secretions or exudate within airways or inflammation and edema in the pulmonary tissue. Finecoarse
Interventions: Diuretics, Turn & position ,Deep breathing ,Forced expiration ,Vibration & percussion

wheezes: musical or whistling sound, results form constriction or obstruction of throat, pharynx, trachea, bronchi.
Associated with asthma. Mostly heard on expiration. Interventions: Bronchodilation, Hydration , Coughing

Rhonchi: bubbling sound, Louder than rales due to larger secretions, Results from air bubbling past secretions in the
airways, heard throughout inspiration and expiration. Interventions:

Deep breathing

Coughing

Hydration (encourage fluids, if no restriction)

Humidify air

Mobilize

Rub: creaking, leathery sound, Caused by rubbing of inflamed pleural surfaces against lung
inspiration and beginning of expiration

Tuberculosis

-transmitted via airborn transmission

-factors that contribute to the incidence of TB:

tissue, heard at end of

- physical environment (crowding, prolonged contact, poor ventilation)

- psycological environment (stress, drugs)

-social environment (homelessness)

- poor nutrition

-lack of medical attention

- increased immigration

-increased drug resistance

2 interventions health nurses can do to control the spreas of TB in people who live in the street: 1)direct observed therapy
2) teach hygeine 3) identify facilities that provide meals 4) evaluate side-effects of medications 5) identify at-risk people
6) identify other living arrangements

Dehydration

Dehydration occurs when your body loses too much fluid. When you stop drinking water or lose large amounts of fluids
through diarrhea, vomiting, sweating, or strenuous exercise, your body's cells absorb fluid from the blood and other body
tissues. When you are not drinking enough fluids, your muscles begin to get tired and you may have leg cramps or feel faint.
By the time you become severely dehydrated, there is no longer enough fluid in the body to get blood to your organs. You
may begin to go into shock, a life-threatening condition.

* Glucose and electrolyte based fluids (7-up, gatoraid, poweraid) are the best when gastric discomfort first occurs to avoid a
fluide/lyte imbalance.

Dehydration can occur at any age, but it is most dangerous for babies, small children, and older adults.

assess: skin turgur, wt, mucouse membranes, pulse, BP, vitals, urine concentration

Constipation

Causes: codiene, iron, caffiene, little activity, high-fiber diet

Symptoms: hard stools, distention, discomfort, anorexia, decreases bowel sounds, nausea, dizzy, headache, increased
flatulence, rectal pressure,

Treatment: more water, dietary fiber, activity, limit caffiene, colace, sennokot

Take metmucil 2 hours after other pills, as it will affect the absorption of other meds.

Electrolyte Imbalance

The serum electrolytes include:

Sodium (Na+)helps balance fluid levels in the body and facilitates neuromuscular functioning.

Potassium (K+) helps to regulate neuromuscular function and osmotic pressure.

Calcium (Ca2+)affects neuromuscular performance and contributes to skeletal growth and blood coagulation.

Magnesium (Mg2+) Influences muscle contractions and intracellular activity

Chloride (CI-)helps regulates blood pressure.

Phosphate (HPO4-)that impacts metabolism and regulates acid-base balance and calcium levels.

Bicarbonate (HCO3-) assists in the regulation of blood pH levels. Bicarbonate insufficiencies and elevations
cause acid-base disorders (i.e., acidosis, alkalosis).

Medications, chronic diseases, and trauma (i.e., burns, fractures etc.) may cause the concentration of certain electrolytes in
the body to become too high (hyper-) or too low (hypo-). When this happens, an electrolyte imbalance, or disorder, results.

HYPERNATREMIA

Sodium helps the kidneys to regulate the amount of water the body retains or excretes. Consequently, individuals with
elevated serum sodium levels also suffer from a loss of fluids, or dehydration. Hypernatremia can be caused by inadequate
water intake, excessive fluid loss (i.e., diabetes insipidus, kidney disease, severe burns, and prolonged vomiting or
diarrhea), or sodium retention. Symptoms of hypernatremia include:

thirst

irregular heartbeat (tachycardia)

irritability

fatigue

lethargy

heavy, labored breathing

muscle twitching and/or seizures

HYPONATREMIA

Up to 1% of all hospitalized patients develop hyponatremia, making it one of the most common electrolyte disorders.
Diuretics, certain psychoactive drugs (i.e., fluoxetine, sertraline, haloperidol), specific antipsychotics (lithium),
vasopressin, chlorpropamide, the illicit drug "ecstasy," and other pharmaceuticals can cause decreased sodium levels, or
hyponatremia. Low sodium levels may also be triggered by inadequate dietary intake of sodium, excessive perspiration,
water intoxication, and impairment of adrenal gland or kidney function. Symptoms of hyponatremia include:

nausea, abdominal cramping, and/or vomiting

headache

edema (swelling)

muscle weakness and/or tremor

paralysis

disorientation

slowed breathing

seizures

coma

HYPERKALEMIA (remember, K+ is the #1 cation INSIDE cells)

Hyperkalemia may be caused by ketoacidosis (diabetic coma), myocardial infarction (heart attack), severe burns, kidney
failure, fasting, bulimia nervosa, gastrointestinal bleeding, adrenal insufficiency, or Addison's disease. Diuretic drugs,
cyclosporin, lithium, heparin, ACE inhibitors, beta blockers, and trimethoprim can increase serum potassium levels, as can
heavy exercise. The condition may also be secondary to hypernatremia (low serum concentrations of sodium). Symptoms
may include:

weakness

nausea and/or abdominal pain

irregular heartbeat (arrhythmia)

diarrhea

muscle pain

HYPOKALEMIA

Severe dehydration, aldosteronism, Cushing's syndrome, kidney disease, long-term diuretic therapy, certain penicillins,
laxative abuse, congestive heart failure, and adrenal gland impairments can all cause depletion of potassium levels in the
bloodstream. Symptoms of hypokalemia include:

weakness

paralysis

increased urination

irregular heartbeat (arrhythmia)

orthostatic hypotension

muscle pain

tetany

HYPERCALCEMIA

Blood calcium levels may be elevated in cases of thyroid disorder, multiple myeloma, metastatic cancer, multiple bone
fractures, milk-alkali syndrome, and Paget's disease. Excessive use of calcium-containing supplements and certain over-thecounter medications (i.e., antacids) may also cause hypercalcemia. Symptoms include:

fatigue

constipation

depression

confusion

muscle pain

nausea and vomiting

dehydration

increased urination

irregular heartbeat (arrhythmia)

HYPOCALCEMIA

Thyroid disorders, kidney failure, severe burns, sepsis, vitamin D deficiency, and medications such as heparin and
glucogan can deplete blood calcium levels. Lowered levels cause:

muscle cramps and spasms

tetany and/or convulsions

mood changes (depression, irritability)

dry skin

brittle nails

facial twitching

Chronic Obstructive Pulmonary Disease (COPD)

-refers to a group of disorders that damage the lungs and make breathing increasingly more difficult over time. Both are
chronic (long-term) illnesses that impair airflow in the lungs. The two most common forms of COPD are:

chronic bronchitis the air passages in the lungs are inflamed, and the mucus-producing glands in the larger
air passages of the lungs (bronchi) are enlarged. These enlarged glands produce too much mucus, which triggers a
cough. In chronic bronchitis, this cough lasts for at least three months of the year for two consecutive years

emphysema the tiny air sacs in the lungs, called alveoli, are destroyed. The lungs are unable to contract
fully and gradually lose elasticity. Holes develop in the lung tissue, reducing the lungs' ability to exchange oxygen for
carbon dioxide. As a result, breathing may become labored and inefficient, and you may feel breathless most of the time

** when applying O2, watch for drowsiness, decreased resps, and lethargy.

Renal Failure

The kidneys lose their ability to filter enough waste products from the blood and to regulate the body's balance of salt and
water. Eventually, the kidneys slow their production of urine, or stop producing it completely. Waste products and water
accumulate in the body. This can lead to a potentially life-threatening overload of fluids (such as congestive heart
failure), a dangerous accumulation of waste products in the blood, and extreme changes in blood chemistry that
eventually can affect the function of the heart and brain. There are three types of RF:

Acute renal failure the kidneys stop functioning properly because of a sudden illness, a medication or medical
condition that causes one of the following:

o A severe drop in blood pressure or an interruption in the normal blood flow to the kidneys, which can occur

during major surgery, severe burns with fluid loss through burned skin, massive bleeding (hemorrhage) or a
heart attack that severely affects heart function.

o Direct damage to kidney cells or to the kidneys' filtering units, which can be caused by an inflammation of

the kidneys called glomerulonephritis, toxic chemicals, medications and infections.

o Blocked urine flow from the kidney, which can occur because of obstructions outside the kidney, such as

kidney stones, bladder tumors or an enlarged prostate. Blockage of urine flow within the kidney also can
cause sudden kidney failure, as can occur with major muscle injury.

o If left untreated, acute renal failure can cause congestive heart failure (because the extra fluid backs up

behind the heart into the lungs)and cardiac rhythm abnormalities

o Measure output every hour!!!!

o should eat a low-protein, high carb, high fat diet. Appitite is best in am, therefor a high cal breakfast is best

Chronic renal failure the functioning of the kidney gradually declines, usually over a period of years. Most
commonly, it is caused by illnesses such as diabetes, uncontrolled high blood pressure or chronic kidney
inflammation (glomerulonephritis or pyelonephritis).

End-stage renal disease kidney function deteriorates until the person dies. This is usually the end result of
longstanding chronic renal failure, but occasionally, it also follows acute renal failure. May be drowsy and
confused at this point. Watch for their safety.

Oliguria= no peeing

Cerebral Vascular Accident (CVA)= Stroke

the blood supply to a part of the brain is suddenly diminished or cut off. There are two major types of stroke:

Ischemic stroke is the most common type of stroke. It is characterized by the presence of a blood clot that blocks
the flow of blood to one area of the brain, depriving that area of oxygen.

Thrombotic stroke is a type of ischemic stroke, accounts for 40 percent to 50 percent of all cases of stroke. In
thrombotic stroke, a blood clot forms in one of the brain's arteries, blocking blood flow to the brain. In most cases,
the artery was already narrowed as a result of atherosclerosis (fatty build-up).

Embolic stroke is a type of ischemic stroke, accounts for 20 percent of all cases of stroke. In embolic stroke, a blood
clot originates in the heart or in blood vessels outside of the brain and travels to one of the brains arteries,
obstructing the flow of blood.

Hemorrhagic stroke accounts for 10 percent to 15 percent of all cases of stroke. In hemorrhagic stroke, bleeding in
the brain itself (intracerebral hemorrhage) or between the brain and the skull (subarachnoid hemorrhage) disrupts
brain function. Bleeding usually occurs because of a rupture in arterial walls that are already weakened by high
blood pressure. A pool of blood compresses brain tissue in its vicinity, preventing adequate amounts of fresh blood
from reaching the area.

Stroke is a medical emergency. Both ischemic and hemorrhagic strokes may have devastating consequences. However, of the
two types, hemorrhagic stroke is more likely to be deadly.

**early nursing intervention for hemiplegia=passive ROM's to affected side

*** Risk factors: hypertension, smoking, atherosclerosis, diabetes, obesity, sedentary lifestyle, hyperlipidemia, A.Fib, clot
disorder, birth control pills, cardiac disease, TIA's, substance abuse,

*** Meds appropriate for ishemic stroke: 1) anticoagulants (heparin, coumadin) 2) Thrombolytic therapy 3) antiplatlet
therapy (ASA), 4) Diuretics (Lasix) 5) Calcium Channel blockers 6) barbiturates 7) anticonvulsants 8) hyperosmotics

According to our VIHA orientationthere is a 3 hour window in which tPA can be administered successfully to ischemic
stroke patients.
Transient Ischemic Attack (TIA)
sometimes called a "mini-stroke," is an episode of stroke-like symptoms that lasts less than 24 hours, usually five to 20
minutes. In a TIA, circulation to a part of the brain is interrupted briefly, then restored. This interruption can result from a
narrowing of a brain artery because of atherosclerosis or a small floating blood clot that entered the bloodstream from
somewhere else in the body, often the heart, and temporarily blocked a brain artery.

HIV/AIDS

The human immunodeficiency virus (HIV) weakens the body's immune defenses by destroying CD4-lymphocytesperson
becomes vulnerable to many different types of infections. These infections are called opportunistic because they have an
opportunity to invade the body when the immune defenses are weak. HIV infection also increases the risk of certain cancers,
illnesses of the brain (neurological) and nerves, body wasting and death.

The virus is spread through contact with an infected person's body fluids, especially through blood, semen and vaginal fluids.
Once inside the body, HIV particles invade CD4 lymphocytes and use the cells' own genetic material to produce billions of
new HIV particles. These new particles cause the infected CD4 cell to burst (lyse). The new particles can then enter the
bloodstream and infect other cells. Eventually, the number of normal CD4 cells drops below the threshold level needed to
defend the body against infections, and the person develops AIDS.

Hep B

-Symptoms: muscle aches, jaundice, anorexia, diarrhea

-spread thru unprotected sex, blood, body fluids

-encourage pt. To resume activities gradually,

- diet: hight in carbs for healing, low proteins as the liver can't metabolize protein by-products

Surgery Complications:

1. Shock

Shock is a medical emergency in which the organs and tissues of the body are not receiving an adequate flow of blood. This
deprives the organs and tissues of oxygen and allows the buildup of waste products. Shock can result in serious damage or
even death.

Causes and symptoms

Shock is caused by three major categories of problems:

cardiogenic problems associated with the heart's functioning

hypovolemic the total volume of blood available to circulate is low , and

septic shock caused by overwhelming infection, usually by bacteria

Cardiogenic shock can be caused by any disease, or event, which prevents the heart muscle from pumping strongly and
consistently enough to circulate the blood normally. Heart attack, conditions which cause inflammation of the heart muscle
(myocarditis), disturbances of the electrical rhythm of the heart, any kind of mass or fluid accumulation and/or blood clot
which interferes with flow out of the heart can all significantly affect the heart's ability to adequately pump a normal quantity
of blood.

Hypovolemic shock occurs when the total volume of blood in the body falls well below normal. This can occur when there
is excess fluid loss, as in dehydration due to severe vomiting or diarrhea, diseases which cause excess urination (diabetes
insipidus, diabetes mellitus, and kidney failure), extensive burns, blockage in the intestine, inflammation of the pancreas

(pancreatitis), or severe bleeding.

Septic shock can occur when an untreated or inadequately treated infection (usually bacterial) is allowed to progress.
Bacteria often produce poisonous chemicals (toxins) which can cause injury throughout the body. When large quantities of
these bacteria, and their toxins, begin circulating in the bloodstream, every organ and tissue in the body is at risk of their
damaging effects. The most damaging consequences of these bacteria and toxins include poor functioning of the heart
muscle; widening of the diameter of the blood vessels; a drop in blood pressure; activation of the blood clotting system,
causing blood clots, followed by a risk of uncontrollable bleeding; damage to the lungs, causing acute respiratory distress
syndrome; liver failure; kidney failure; and coma.

Initial symptoms of shock include:

cold, clammy hands and feet;

pale or blue-tinged skin tone;

weak, , thready, fast pulse rate;

fast rate of breathing;

low blood pressure.

Irreversible phase of hypovolemic shock: rapid, shallow breathing, crackles and wheezes

**** put on O2 and place in trendelenberg

Treatment includes keeping the patient warm, with legs raised and head down to improve blood flow to the brain, putting a
needle in a vein in order to give fluids or blood transfusions, as necessary; giving the patient extra oxygen to breathe and
medications to improve the heart's functioning; and treating the underlying condition which led to shock.

2. Hemorrhage

3. Deep vein thrombosis (DVT)

A common but difficult to detect illness that can be fatal if not treated effectively. Can cause pulmonary embolism, a
potentially fatal complication where the blood clots break off and form pulmonary emboli, plugs that block the lung arteries.
Deep vein thrombosis is also called thrombophlebitis

Deep vein thrombosis is a major complication in patients who have had orthopedic surgery or pelvic, abdominal, or
thoracic surgery. Patients with cancer and other chronic illnesses (including congestive heart failure), as well as those who
have suffered a recent myocardial infarction, are also at high risk for developing DVT. Deep vein thrombosis can be chronic,
with recurrent episodes.

Symptoms pain, redness (Erythema) , swelling, warmth in affected areaalso positive Homans sign.

4. Infection

5. Air emboli: place ot on left side to prevent air from entering the pulmonary circulation

ETOH withdrawal Symptoms

Early symptoms These usually begin within five to 10 hours after the last alcoholic drink and typically peak at 24 to
48 hours. Symptoms may include: tremors, rapid pulse,an increase in blood pressure, rapid breathing, fever, sweating,
nausea and vomiting, anxiety, depressed mood, irritability, nightmares and insomnia.
Alcohol-withdrawal seizures ("rum fits") These may occur six to 48 hours after the last drink; the risk peaks at 24
hours.
Delirium tremens Delirium tremens commonly begins two to three days after the last alcoholic drink, with peak
intensity at four to five days. Symptoms include confusion, disorientation, changes in levels of consciousness, agitation
(being very upset), delusions (irrational beliefs), sleep disturbances and hallucinations. Visual hallucinations may be
especially common, although it is not clear why.
MEDICATIONS

* If a med error occurs FIRST assess pt, then call Dr.

LASIX: (diuretic)
Indications: treatment of edema associated with congestive heart failure, cirrhosis of the liver, and renal disease.
Overdose Symptoms: dehydration, electrolyte depletion & hypotension.
Adverse Reactions: CNS-headache, restlessness
CV-hypotension
GI- pancreatitis, abd pain and discomfort.
GU- polyuria
Nursing Care: Monitor weight, B.P & pulse.
Monitor fluid intake and output.
**potent diuretic can lead to profound diuresis with water and electrolyte depletion. Monitor for hyokalemia.
DIGOXIN
Action: Strengthens myocardial contractions by inhibiting sodium potassium activated adenosine triphosphatase.
Indications: heart failure, atrial fib.
Adverse reactions: CNS-fatigue, muscle weakness
CV-arrhymias
GI anorexia, nausea vomiting,

Nursing Considerations: Use with extreme caution in the elderly and in those with acute MI, renal insufficiency, and other
heart conditions.
Before administering a loading dose, obtain baseline data (heart rate, rhythm, B.P. and electrolytes). Loading dose is divided
over a 24 hr period.
Before administering drug take apical pulse for 1min,
Monitor serum digoxin levels, therapeutic levels range from 0.5-2ng/ml.
**excessive slowing of the pulse (60 beats or less) maybe signs of toxicity, monitor serum potassium levels and take action
before hypokalemia occurs, withhold drug and call physician.
S/S of toxicity: anorexia, n&v, headache, fatigue, depression, confusion, nightmares, weakness
MORPHINE
CNS drug, Narcotic & Opioid analgesics
Aka: morphine sulfate, epimorph, MS Contin, MSIR
Indications: severe pain
S/S overdose: extreme sedation, resps <12/min.
** causes vasodilation, therefor it can be perscribed to pt.s with SOB, crackles and chest pain, and together with lasix, it will
decrease crackles and lead to ++ diuresis
Nursing considerations:
- keep narcotic antagonist NALOXONE & resuscitation equip. available
- dont crush or chew extended release tabs.
- epidural Route: monitor resps. closely for resp. depression (check Q30-60min.x 24hr)
- may cause transient decrease in BP
- constipation commonly severe with maintenance dose, ensure stool softners are ordered
- monitor circulatory, respiratory, bladder & bowel functions carefully
- N+V are common side effects
ATROPINE
Cardiovascular system drugs, Antiarrhythmics
Aka: atropine sulfate
Indications: symptomatic bradycardia, bradyarrhythmia (junctional or escape rhythm), antidote for anti-cholinesterase
insecticide poisoning, preoperatively to diminish secretions & block cardiac vagal reflexes, adjunct Tx of peptic Dx, Tx of
functional GI disorders such as IBS (irritable bowel syndrome)
S/S overdose:
Nursing considerations:
- use cautiously in Pts with Down syndrome may have increased sensitivity to drug
- many adverse reactions (incl. dry mouth & constipation)
- watch for tachycardia in cardiac Pts may lead to ventricular fibrillation
- monitor fluid intake & urine output drug causes urine retention & urine hesitancy
-

suggest use of sunglasses to those who experience photophobia

ANTIHYPERTENSIVES

Antihypertensives the olols : beta blockers

and prils: ACE inhibitors

Metoprolol

Ramipril

Propranolol

Quinapril

Action: myocardial contractibility

III

Action: Prevents conversion of angiotensin

HR (Angiotension II is a potent vasoconstrictor)

Cardiac output

BP

myocardial O2need

Adverse Rx: bradycardia, Hypotension, Heart failure

INSULIN

(Blue namesnew VIHA drug stockNovo Nordisk Insulin) Effective Jan 2005
Type

Brand Name

Rapid acting Humalog

Novorapid

Onset

Peak Duration Comments

Within
10
minutes
30
minutes

45 - 90 3 -5
minute hours
s
2 - 4 8 hours
hours

Intermediate Humulin N
acting
Novolin NPH

1.5
hours

6-8
hours

Mixtures

30
2-5
24 hours
minutes hours
and
6-12
hours

Short acting
(regular)

Humulin R
Novolin
Toronto

Humulin
70/30
Novolin 70/30

Rapid acting, Human

Human
Often injected before meals to
compensate for the sugar intake
from food
24 hours Human

The numbers refer to percentage

of NPH (1st number) and regular
(2nd number)
Available in vials, pen-fill
cartridges, and prefilled syringe

Discard all vials 30 days after opening

Heparin anticoagulant

prevents conversion of fibrinogen to fibrin (Therefore, prevent blood clots)

for prevention of post-op DVT, MI, PE

also for patency maintenance of indwelling catheters

Routes: IV drip, SC

Adverse Rx: hemorrhage, overly prolonged clotting times (PT-INR, PTT) thrombocytopenia

Monitor PT-INR and PTT

Dosage is highly individualized based on age, disease state, renal and hepatic function

NITRO
NITRO Cardiovascular system drug, Antianginals
Aka: nitroglycerine, glyceryl trinitrate, Nitro-Bid, Nitro-Dur, Transderm-Nitro
Indications: prophylaxis against chronic anginal attacks, acute angina pectoris, prophylaxis to prevent or minimize anginal
attacks before stressful events, HTN from Sx, heart failure after MI, angina pectoris in acute situations, to produce controlled
hypotension during Sx (by I.V. infusion)
S/S overdose:
Nursing considerations:
- use cautiously in Pts with hypotension or volume depletion
- ** closely monitor VS during infusion***especially BP in Pts with an MI excessive hypotension may worsen the
MI***
- wear gloves applying ointment or patch to avoid absorption of drug NB to remove old transdermal patch before
applying new one.*** remove patch before defibrillationmay cause electric current to arch that can damage
paddles and burn Pt.
- ** gradually decrease dose & frequency of transdermal patch when stopping Tx.
- Monitor BP& intensity& duration of drug response
- drug may cause headaches during start of Tx treat headaches with Tylenol or aspirin
- advise Pts to avoid alcohol increased hypotension
- teach Pt: sublingual dose may be repeated x3 q5 min if no relief, obtain med. help immediately
LITHIUM (anti-manic/mood stabilizer)
Blood levels only a little above the therapeutic level range may lead to serious adverse effects. Therapeutic Blood Serum
Levels: 0.6 to 1.2 mEq/L (though levels of 1.5mEq/L are sometimes required for control of acute symptoms) Checked every
6 months
Anything above 1.2 to 1.5mEq/L is considered lithium toxicity
Symptoms of lithium toxicity: lethargy and dizziness

If levels are very high an EKG will show significant changes potentially fatal cardiac toxicity
Be aware of sodium intake may lead to toxicity without a change in dose
Due to unwanted side effects, lithium is difficult to take over an extended time i.e. thirst and polyuria, tremor, weight gain,
chronic diarrhea (this is also an early sign of toxicity)
* medication usually taken indefinitely
*** Salt and liquids in a diet is important to reduce risks of lithium toxicity
ANTI-ANXIETY DRUGS
(Also used for short-term insomnia as they induce sleep and decrease the frequency of awakening)
Benzodiazepines (the pams):
i.e. Xanax, Diazepam, Valium, Lorazepam (Ativan), Clonazepam
Diazepam and Valium have long half-lives & are better for longer treatment plans whereas Ativan and Clonazepam have
shorter half-lives & are good for intermittent symptom-driven treatment
May produce dependence
Side Effects: sedation, occasional amnesia, physical dependence
ANTI PSYCHOTIC DRUGS
Given to control symptoms of psychosis (: a state in which an individual has lost the ability to recognize reality) (i.e.
hallucinations, bizarre behavior & paranoid behavior) and prevent relapse. They produce a claming effect without sedating
the pt.
Specific Drugs:
Haldol (Haloperidol)
Clozapine (Clozaril) an atypical anti psychotic for treatment of schizophrenia & bipolar psychosis
Chlorpromazine
Atypical Neuroleptics (i.e. Risperidine & Olanzapine) are preferentially used as initial treatments for clients with previously
untreated psychosis
Side effects in 1st few days: frightened expression and difficulty pronouncing words. These indicate an acute dystonic
reation, which are reversible with antiparkinsons drugs (ie.benztropine mesylate or cogentin)
Side Effects: constipation, dry mouth, blurred vision, postural hypertension, urinary hesitation or frequency, weight gain,
sedation
Serious Adverse Effects:
Akathisia (most common): sense of restlessness with a perceived need to pace or move continuously (easy to be mistaken for
anxiety or agitation)
Dystonia: sustained, involuntary muscle spasms, commonly of head & neck
Oculogyric Crisis: extraocular muscle spasms forces the eyes into a fixed, usually upward gaze
Tardive Dyskinesia: a neurological disorder characterized by involuntary movements, most commonly tongue and lips
(grimacing/sucking movements/lip smacking)
Neurolpetic Malignant Syndrome (seen with all anti psych meds): sudden fever, rigidity, tachycardia, hypertension,
decreased LOC & death may occur (Treatment stop psych meds and administer anit-parkisonian meds)
*** antidepressants can take upto 4 weeks to kick in
Normal Lab Values
LUNGS:
blood pH: 7.35-7.45
pCO2: 25-45

HCO3: 20-24
LIVER:

PT-INR: 0.9-1.1
PTT: 23-33seconds
Protein: 63-77

Albumin: 38-53
Urine pH: 5-8
URINE:
spec gravity: 1.010-1.
BLOOD/ CARDIAC ENZYMES:
KIDNEYS:
Hb (male): 136-170 (female): 120-150
Potassium: 3.5-5.0
WBC: 4.0-10.5
Sodium: 135-145
Troponin: 0-1.5Myoglobin: 0-85
Urea: 3.0-7.5
CKMB: 0-8
Creatinine: 60-110
Chloride: 101-111
Bicarbonate: 24-3
CBC= WBC's, hematocrit, hemoglobin, RBC's
electrolytes= Na, K, Cl
Kidney function= KFT, creatinine, BUN
Blood Administration/ Reactions
wear gloves at all times
Vitals done immediately before transfusion, in 5 minutes, and in 15 minutes, then hourly throughout transfusion
Blood to be administered thru primary line, not piggybacked
NS at 50 mls to establish IV. Always needs to be a bag of NS and tubing at bedside
Blood to be administered through 20 gauge or larger IV
RL, D5W, half NS cannot come in contact with Blood
If NS is to be added to blood, must have Dr.s order, and no more than 50 mls to be used, and it must be added
IMMEDIATELY before transfusion
8) IF dr's order, Frozen plasma, stored plasma, 5% albumin can be added to packed RBC immediately before transfusion
9) If blood not hung immediately, return to bank within 30 mins of sign-out time
10)
Do not put blood in any other refrigerator
11)
usual time is 1.5-2 hours to infuse. Cannot take longer than four hours. If not transfused within 4 hours, DC and
discard in biohazard bin. Notify Dr. of amount transfused.
12)
Change transfusion set after each unit.
13)
Do not flush tubing after administering blood
14)
Infuse blood slowly for the first 15 minutes
15)
When infusion more than one unit, attach an extension set IVI, to decrease manipulation of site. When all infusions
are dome, MUST remove extension set
16)
A transfusion reaction report must be filled out for both MINOR and MAJOR reactions and top 2 copies are sent to
transfusion services
17)
Pt's should be on bed rest during transfusion. If they need to leave the ward, they are to be accompanied by an RN
18)
Pressure infuser cuffs to be used when ordered by DR. for rapid infusion (ie. Hemorrhage)
19)
Transfusion services to be called asap to cancel any previosly ordered blood that is no longer needed.
1)
2)
3)
4)
5)
6)
7)

Blood Transfusion Rxs: can happen during, immed. after or up to 4 days after infusion

1. Hemolytic: ABO incompatibility, chills, shakes fever, flushed skin, flank pain, stop transfusion, TKVO with N/S,
call Dr. stat, monitor VS, I/O, bleeding, repeat type and cross match

2. Febrile: an 1 degree C with no other medical reason, blood is contaminated with bacteria, similar s/s to hemolytic,
stop infusion, TKVO with N/S , call Dr stat, can occur within 4 hours of start of transfusion

3. Allergic: milditching, chills, fever, N/Vjust SLOW DOWN transfusion. Severetight chest, diff.
swallowing STOP INFUSION call Dr stat, kiss your career goodbye.
ARO/Universal Precautions:

-private room or with pt. With same ARO

-isolation sign on door
-wash hands with chlorhexine
-if ARO is MRSA, wash pt qweekly with chlorhexine
-gown gloves and mask
-out of room procedure: write isolation and precautions on req, and notify dept.
-needs three consecutive negative cultures from all sites taken when off antibiotics
SC Butterfly:
-prime with highest concentration of med (i.e. 10Mg/ml if hydromorphine)
-mark on tegadern date of insertion, initials, and dose concentration
-change q7d unless red/inflammed
CVC
-transparent drsg change q5d
-gauze/mepore drsg change q2d
- Most common complication= air emboli, therefore regularly check for chest pain, & dyspnea
-cap change q5daysFlush unused lumen OD with 3cc syringe
-***notify DR. if movement more than 5cm OR 10cm or less of CVC internally
-To draw blood: flush with 10cc NS in 10 cc syringe, and draw back 10cc for discard. With new 10 cc syringe, draw back
10 cc blood, then flush again with 10 cc NS.
-To give meds: flush before and after with 10 cc NS

PICC
Change drsg q5-7d by IV team
cleaning solution is 2% chlorhexidine
tip should be in superior vena cava
flush ports by IVT
warm compress ofter insertion for 20 mins, then TID
Assess for roping, reddness, swelling, drainage
Document measurement
Use 12 cc syringe, flush with 5cc NS, and flush with 20 mls NS after with syringe larger than 12 cc.
To give meds, flush with 5 cc NS before and after in 12 cc syringe.
***ensure blood can be aspirated thru catheter prior to infusions. If it can't be aspirated, there is risk of pushing clot thru
catheter.

Infuser changes q72hrs by IVT,

flush before and after use with 3cc NS
change main bag q24h
change tubing q72h and label

Infuser:

Epidural
change filter and tubing q3days
drsg change q5d with order or when leakin, with 2 people
change med bags q72hr
-if witnssed disconnect: both ends sterile and reconnect
-if unwittnessed disconnect: cover catheter with sterile gauze, call anesthetist
-PCA: Cleaning shift totals at 100 and 2200

Tube Feeds
-need baseline 6/60, serum glucose and albumin
-repeat q monday and thursday

-keep HOB up 10 degrees

-do not hang more than 4 hours of formula at a time
-aspirate for gastric residules, DO NOT aspitage if in duodenum or jejunum
-flush with 60 ml syringe (only after feedings, not before)
-flush before and after meds with 20 ml water
-flush and wash bag and tube q4h
-wt. pt. Q weekly
-change bag q48h
TPN
-vitals q4h and s/s fluid overload
-call dr. if central line site inflammed or temp over 39
-on I and O's
-weigh mon and thur am
-change iv tubing q 72h
-notify pharmacy if TPN order changes by 1100
-BW daily X 3d than q mon and thursday
-if TPN no available, hang d10W at 50ml/hr
TPN Complications

1. S

2. Sepsis

3. hyperglycemia (most common)

4. hypoglycemia

5. osmotic diuresis: r/t hyperglycemia

6. fluid excess

7. fluid deficit

8. electrolyte imbalance
Restraints
Safety measures: Use minimum restraint, educate family, assess appropriateness of restraint, apply appropriate restraint,
Aviod putting it over IV, Check for tightness, pad skin and bony prominences, document use, call bell in reach, bed in lowest
position, provide sensory stimulation, wheels on bed locked, release at regular intervals,
Ethical issues: loss of personal freedom, loss of personal dignity, risk of injury or harm to person
Nursing interventions before applying restraints: assess need, review agency policy, Dr.'s order?, explore alternatives, inspect
skin condition of area, explain purpose, obtain consent

Suctioning:
-suction while withdrawing
-consious pt. Should be in semi-fowlers, uncounsious= side-lying
PRACTICAL ISSUES
Steps when short staffed
- assess needs of clients, RN take most acute
if tasks are delagated to RCA/LPN, make sure to get verbal feedback in timely manner
If the ER is about to be overloaded, first activate on-call list
request for extra assistance on the ward
If a new nurse, or float nurse comes onto a ward with a new acute pt., review what should be assessed, and what should
be reported.
Conflict resolution with staff
-always speak with colleague about unsafe, unethical behavior first
important to be able to disagree with each others ideas, but not the other persons competence (ie. I do not agree with
you on this particular point)
Prioritizing duties
Assess: urgency of the situation, chain effect of problem, available resources, & time limits

Reporting unsafe practice

If a nurse observes another nurse contaminate the sterile field when inserting a foley, immediately inform them
If you suspect another nurse has been drinking, report to nurse in charge

HEALTH CARE/ TRENDS

Self-breast exam
should be done every month, especially in older women
Birth Control
Oral Contraceptives: () Synthetic estrogen and some progesterone.
Monophasic= day cycle, Triphasic= throughout cycle
Benefits: dysmenorrhea, anemia, Decreased PID, Decrease of ovarian and endometrial Cancer and cysts, breast diseases
Side effects: Nausea, Wt. Gain, Headache, Breast tenderness, Spotting, Infections, Hypertension, Depression
Contraindications: (Absolute): Beast-feeding, family History of CVA/CAD, Thromboembolic Disease, Liver Disease,
Vag. Bleeding., interfere with glucose metabolism, penicillin, barbiturates, tetracycline, Tylenol, anticoagulants,
anticonvulsants. (Possible): Over 40, breast/Vag malignancy, DM, Increased cholesterol, hypertension, mental
depression, migraine, obesity, seizures, sickle cell, smoking.
SC Implants: (Norplant) 6 implants with synthetic progesterone, works over 5 yrs.
Side effects: Cost, wt. Gain, irregular. Cycle, hair loss, depression, scaring.
No sexual side effects, can be used in adolescence, or with breastfeeding, rapid return of fertility.
IM Injections: (DMPA/Depo-provera), every 12 weeks, synthetic estrogen and progesterone, nearly 100% effective,
increase risk for OA.
IUD'S: plastic inserted into uterus, can cause PID, low cost
Barrier Methods: Spermicide, Diaphragm (cause UTI's), cervical caps, Vag rings, Male and female condoms
CRNBC Ethics
Safe, Competent and Ethical Care: Nurses value the ability to provide safe, competent and
ethical care that allows them to fulfill their ethical and professional obligations to the people they serve
Health and Well-being Nurses value health promotion and well-being and assisting persons to achieve their optimum level
of health in situations of normal health, illness, injury, disability or at the end of life.
Choice Nurses respect and promote the autonomy of persons and help them to express their health needs and values and also
to obtain desired information and services so they can make informed decisions.
Dignity Nurses recognize and respect the inherent worth of each person and advocate for respectful treatment of all persons.
Confidentiality Nurses safeguard information learned in the context of a professional relationship, and ensure it is shared

outside the health care team only with the persons informed consent, or as may be legally required, or where the failure to
disclose would cause significant harm.
Justice Nurses uphold principles of equity and fairness to assist persons in receiving a share of health services and resources
proportionate to their needs and in promoting social justice.
Accountability Nurses are answerable for their practice, and they act in a manner consistent with their professional
responsibilities and standards of practice.
Quality Practice Environments Nurses value and advocate for practice environments that have the organizational structures
and resources necessary to ensure safety.
If a nurse observes another nurse breaking a code, they should: follow can code of ethics, review existing policies, review
private legislations, discuss with collegue, inform nurse-in-charge, in-service to revie confidentiality pronciples
Principles of Communication
-Use open ended questions,
-Active listening,
-paraphrasing
reflecting
exploring
silence
clarifying
eye contact
body language
circular questions

Determinants of Health

1. Income and Social Status

2. Social Support Networks
3. Education and Literacy
4. Employment/Working Conditions
5. Social Environments
6. Physical Environments
7. Personal Health Practices and Coping Skills
8. Healthy Child Development
9. Biology and Genetic Endowment
10.
Health Services
11.
Gender
12.
Culture

EXTRAS
Trundelenberg: head down

Sims position: A semiprone position with patient on left side, right knee and thigh drawn well up, left arm along patients
back, and chest inclined forward so patient rests upon it. It is the position of choice for administering enemas, because the
sigmoid and descending colon are located on the left side of the body.

Prostaglandins: act as messengers involved in reproduction (contractibility of the uterus) and in the inflammatory response
to infection. Aspirin inhibits prostaglandin synthesis, leading to reduced inflammation.

Dumping syndrome: Rapid gastric emptying happens when the lower end of the small intestine (jejunum) fills too
quickly with undigested food from the stomachnausea, vomiting, bloating, diarrhea, and shortness of breath.

-encourage the use of antiseptic mouthwash to a client with neutropenia fromchemo, as mouth is primary source of infection

A child comes into ER with sore throat, fever, drooling, and odd voice, stridor on inspiration, barking cough, and hoarsness.
DO NOT do visual exam of mouth and throat, as it may start laryngeal spasm, DO prepare hight-humidity croupette.
-transfering a pt? Most important info is currant status, meds, and concerns.

3 measures that a nurse could take to assist a pt. With their discharge:
involve her in all decisions

explore her feelings and thoughts about discharge

explore her perceptions of family support.

-Nursing interventions in health promotion programs are more effective if the nurse first finds the individuals definition of
health
-A pt. States they take herbal meds. Three ways to show respect for this: 1)add to care plan, explore choice, communicate her
choice to care plan, support her choice

2 potentially harmful effects of herbal remedies are: adverse/side effects, interactions with other medicine or food,
toxicity

3 ways to increase knowledge about holistic healing modalities: ask Dr, search Internet article, books, review nursing
literature, review currant research, continuing education.

to involve pt. In development of holistic care plan: 1) explain purpose of plan 2) believe the client 3) assess present pain
control stratagies, include family, identify clients priorities, discuss past expereinces, provide information, encourage
expression, answer questions

*factors that may cause change in urine: new meds, new foods, new products, dehydration, hematuria
nurse can promote normal urinary elimination with a UTI by encouraging: good perineal hygiene, fluid intake,
compliance with drug therapy, avoid caffiene, alcohol, lemon juice, and spicy, avoid bubble baths, wear cotton underwear,

West Nile virus can be prevented by applying a DEET-based insect repellent to exposed skin.

Appropriate use of services is a Primary health care principle.

Causes of Nausea: Anxiety, Pain, morphine

tips for dealing with pt.s with aphasia: active listening, be patient, don't interrupt, ask simple questions, allow for adequate
response time, use visual cues, encouragement, communication aids, minimize distraction,

a pt. Is requesting a new analgesic. The nurse shoulf 1st assess the pain using pain scale, call dr. regarding the assessment,
and then ask for new med orders

- after abdom. Surgery, a pt has to DB & C, spling insicion with pillow, and place pt on side with pillow between flexed legs.
CULTURE
always assess the degree of acculturation of a client when developing care plan
respect the personal spacce during pt interactions, as it influences the meaning of the message
Three cultural traits on Native Americans to assess when assessing pain: NO eye contact, use of traditional healing
practices, do not report pain, do not request pain meds, speaks slowly, personal space

asses perceptions, biological practices, family roles, communication, health-related cultural practices, expression of pain,
self-medication-eating habits, religious practices, social organization

*** sign of increased intercranial pressure in adults= increased systolic BP, decreased pulse

priorities in comfort care: hygein, comfort, emotional support, rest

- hypercapnia: buld-up of co2 in blood, may oocur with spontaneous pneumothorax. Pneumothorax causes unilateral chest
pain, and mediastinal shift towards uneffected side, as well as decreased chest motion.

empowerment in a group/community can be established by:

establishing partnerships, mobilizing a group leader, train trainers, establish a dialogged, and show the benefits

- to give a ventrogluteal IM, the nurse should: 1)place heel of hand over greater trochanter of femur, and 2)form a V between
index and third finger