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Lecture Notes

Lecture Notes


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Published by: Lalaine April E. Ortiola on Oct 30, 2007
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Le Not My Notes: NCLEX

Delegation RN LPN Specialized Care (Inc. Level of skill, Newly recovered) Routine Care Severe Cases Chronic cases Sterile Procedure Stable clients Newly Diagnosed Unstable clients With Complications (acute, life threatening) Assessment, Teaching, Evaluation UAP/NC Activities of Daily Living

o Latex Allergy = Kiwi fruit allergy o History of MVA(head trauma)  Polyuria  Diabetes Insipidus
o Cushing’s triad: 1.) wide pulse pressure 2.) Dec. RR 3.) Dec. PR * Note a dec. in LOC before Cushing’s triad Saw Palmetto = Same as Finasteride  prevents dysuria  given to clients with BPH to dec. the size of prostate. Ma Huang = Same as ephedra  substitute of Sudafed  Shabu or amphetamine like effect Di Huang = Dec. blood sugar for DM Black Cohosh = Inc. Estrogen  for menopause  relieves hot flushes Blue Cohosh = a uterine tonic for starting labor  also after delivery for uterine contraction Chamomile = CI in asthma  causes bronchospasm = CI with gingkobiloba Heart Block = Atropine Sulfate Tachycardia = Lidocaine How many servings of milk, fruit and vegetables a day = 3-4/meal

o o o o o o o o

Chemotherapeutic Agents 1. Cisplastin = causes stomatitis 2. Azathioprine = 3. Methotrexate = Psychotropic precautions Conversion Disturbances Primary Gain Motivation Behind the s/sx Secondary Gain The attention that they get Tertiary Gain Extent to w/c the s/sx is manifested in order to please the health care provider

o Goal on Pre-eclampsia = To prevent seizure o Ileostomy  Normal  2-3 days after (-) discharge
Fat embolism 1.) Dyspnea 2.) Chest pain 3.) Petechiae on the chest o Priority administer O2  To dec. surface tension of fat globules DIC = Disseminated Intravascular Coagulation


o Systemic clotting  bleeding
o Priority = Prevent systemic clotting

o Normal Fibrinogen level = 180-340mg/dl  < 100  bleeding

Narcotic Withdrawal Syndrome • • • • • • • Hypertonicity Hyperactivity Irritability Poor Sucking Sleepiness Shrill cry High pitched cry

Fetal Alcohol Syndrome Hypotonicity Irritability Poor Sucking Facial Deformity Microcephaly

o Priority = Physiologic Integrity  Vitals signs  Give Valium
Macular Degeneration o CMV = Cytomegalovirus infection o Loss of central & peripheral vision  blindness Erb’s Palsy o Attained during delivery  reversible  complete recovery after 3 months Steps of Heimlich Maneuver = stand behind =wrap arms around the client = fist over xiphoid process = upward abdominal thrust Septic Shock o Systemic infection o Centralized vasodilation o Dec. BP o Inc. Temperature Cleft Palate o Post surgery = prone o Post feeding = side lying Cleft Lip & Palate o Post surgery = side lying o Cleft lip is 1st done followed by the repair of the palate o Must first satisfy the rule of 10: 1.) 10 weeks 2.) 10 lbs. 3.) 10 Hgb Situation in which consent of parents are not needed: 1.) STD’s 2.) Delivery 3.) Substance abuse Diabetic Clients o 50-70% CHO


o Raisin  best to bring during travel
o 1 rice is equal to 2 servings of popcorn

MI Sequence of enzymes that increases during MI: 1.) Myoglobin = 30 min-1hr post MI 2.) Troponin = 3-6hrs upto 3 weeks 3.) CK MB = Inc 4 – 8 hrs post MI, back to normal in 3 – 4 days 4.) AST = 8 – 20 u/L normal, Inc 6 – 10 hrs post MI, back to normal a week later 5.) LDH = Inc 2 – 3 days post MI, back to normal by 10 – 14 days LDH = 45 – 90 u/ml Normal LDH 1 = Heart LDH 2 = RES LDH 3 = Lungs LDH 4 = Kidney & Pancreas LDH 5 = Liver Pilocarpine sweat Test (Induce Sweating)  Cystic Fibrosis (Autosomal recessive) Dysthemia  Less severe form of depression Incentive Spirometer  Inhale Peak Flowmeter  Blow as hard as fast as possible Gentamycin Toxic Effects: 1.) Ototoxic 2.) Nephrotoxic 3.) Neurotoxic Influenzae vaccine Varivax  Do not give Aspirin  may lead to Reye’s Syndrome Kwell  CI to pt with seizure Dx Procedures: 1.) 2.) 3.) 4.) 5.) ABG Amniocentesis Thoracocentesis Bronchoscopy MRI

Angiogram: 1.) Capillary Refill time 2.) Distal Pulses 3.) Puncture site for bleeding = If the site is on the femoral  Keep leg extended for 24 hrs.


Respiratory Alkalosis  breath to a paper bag Respiratory Acidosis  Deep Breathing Commonly asked drugs: 1.) 2.) 3.) 4.) 5.) 6.) 7.) Lanoxin Heparin Acetaminophen MgSO4 Cytoxan Synthroid Vaccines

Do the CHECK method Theophylloine = 10-20mg/dl – adult = 5-10mg/dl – pedia Acetaminophen SE = Hard stools Commonly asked diseases: 1.) Alzeihmenrs 2.) Sickle Cell Anemia 3.) Pancreatitis 4.) Bipolar Disorders 5.) Liver Cirrhosis 6.) Hemophilia 7.) AIDS 8.) DM 9.) Cystic Fibrosis Droplet  within 3 feet Airborne  Beyond 3 feet Informed consent o For adult or minor with capacity o Require full understanding of procedure o Protects the client, nurse, surgeon and hospital o For emancipated minors: o Married minors o Military service o Living away from home o Had a child Procedures requiring consent: 1. Surgical Procedure 2. Invasive that requires entry to a body cavity 3. Visualization or radiologic procedure with contrast medium 4. General Anaesthesia, local infiltration and regional block Conditions that doesn’t need parents consent: 15 y/o = antibiotics for acne 16 y/o = pelvic exam 17 y/o = request for contraceptives 18 y/o = Dx exam for recurrent H/A 19 y/o = surgery for bone tumor Assesment o Empowering children to the greatest extent feasible ELEMENTS o Explain to the child his condition and the reason why the procedure has to be done in lay man’s term


o o o

Clinical assessment of patient’s understanding Solicit child’s willingness Expectation

Ethical Care Concept 1.) Autonomy = Living will, freedom of choice, self determination and privacy.

a. Advance Directive = List of don’t’s (client’s with progressive chronic illness in which death is expected) b. Durable Power of Attorney for health Care= appoints a proxy that will decide for the patient.
2.) Beneficence = duty to promote well being of others Ideal Beneficence = “Nag kusa” 3.) Non-Maleficence = Restrained self from doing something that might harm someone. “Do not harm”. 4.) Justice = Fairness Clinical Issues 1. Unsafe nurse/pt ratio Intervention: o Address verbally and document. o Report to charge nurse  Supervisor  director 2. No response by Physician Promote Safety: o Side rails up o Move pt near nurses station o Use restraints appropriately (last resort) 3. Inappropriate order o Document it o Notify the charge nurse o Notify the physician Legal Issues Malpractice = Negligent conduct in rendering prof. service = did not exercise care Respondeat Superior = Superior is responsible to the actions of subordinates. Referral Agencies for special care during admission Pt advocate = Empower pt to know his/her rights and privileges 1.) 2.) 3.) 4.) social worker Children’s protective services Adult protective services Organizations

Care of the hospitalized clients Mantoux Test 15mm = gen. population 10mm = DM, Alcoholism


5mm = HIV Areas where bruises are indicative of child abuse: 1. Lower Back 2. Upper Back 3. Side of the abdomen Special Considerations Infants o o o Greatest risk for fluid and electrolyte imbalance Hypothermia and infections Approach them in non-threatening manner

Toddler o o o Increased separation anxiety Briefly prepare them for procedures due to short attention span Describe sensation that they may feel during procedure

Preschooler o o o o Fear of physical harm Believe that illnesses is a form of punishment Explanations must be brief, honest and in natural terms Use demonstrations and play in providing health teaching Can use adult seatbelt if  40lbs or 40 inches tall, also if he could look at the window in sitting position


School Age o o o Realistic understanding of death = 9 -10 Needs more detailed teachings Allow them to make some choices

Adolescence o o o o o Elderly o o o o Nutrition is a primary concern Muscle atrophy Dec body water, BMR Dec renal, CV, GIT function Dec taste, smell, visual acuity (cataract, arcuc senilis = fatty deposits around pupil_) With multiple medications due to chronic diseases  OH, Nephrotoxic Developed abstract thinking and ability to problem solve Logic and reasoning Full and honest explanation Primary concern are with the present time Focus on appearance

o o

Triage = a system of client evaluation to establish priorities PRINCIPLES


Emergency Situation = greatest risk receives priority Major Disasters = those requiring minimal care are treated first = Those requiring specialized care may be given minimal care or no care

Tree of Strategy for Prioritizing Ask  Where  Disaster Area = Least injured  Emergency Area = Most injured Case Various Areas Physiologic vs. Psychological Acute vs. Chronis Unstable vs. Stable

Look  Same Area = all OB = all Psycho = all MS = all Pedia

Evaluate and look for = Complications = Immediate need = Adverse effects Prioritizing Signs and symptoms Consider = Symptoms related to ABC = symptoms which are indicative of complications Prioritizing Nursing Diagnosis Consider = Tyoe of N. Dx = Actual (Problem) = Risk (Vulnerable) = Possible (Inadequate data) = Wellness Prioritizing Interventions


Diagnostic  Verify the Dx  Assessment Therapeutic  Assess pt Teaching  Informing the patient Referral  Involves a member of the health team Independent  Decision Making Level’s of prioritizing Level 1: Emergent S = evere shcock C = ardiac arrest, Cervical Spine Injury A = irway compromise, altered LOC M = ulti system E = clampsia Level 2: Urgent (stable) Fe = ver Mi = nor burn less 10% Mi = nor musculo Skeletal d/o La = creation Di = zziness Level 3: Chronic / Minor Injuries Dental problems Routine Medications Missed Menses Chronic Low Back Pain Prioritize Cardiovascular = Neurological Cases Acute Complications Consider = Age and Dx of the pt Fort MS Cases: Think “ABC” For Psyche: Safety First In case of fire: ARCE (new) : RACE  If caused by O2, turn off O2 first DELEGATION: Transfer of responsibility for the performance of an activity from one individual to another. Direct: Identified by the RN Indirect: Task based on the families list Complex task = never delegated = requires judgment on how to proceed Non-complex task: can be safely performed recording to exact directions : can be delegated Task that cannot be delegated (HOSPITAL) 1. Administration of: = Investigational drugs = Cancer Drugs = IV push drugs = Blood and blood products = TPN = Implanted device


2. Hemodialysis Functions Task that cannot be delegated (HOME HEALTH) a.) initial set up of pt controlled analgesic pump = changing of flow rates = changing medications reservoir = filling the reservoir b.) NGT feeding KNOW THE RULES 1.) Do not delegate: o Assessment o Teaching o Evaluation o Preparation and administration of meds 2.) Delegate o ADL o Routine o Standard Procedures Know the 5 rights of delegation 1.) Right Task 2.) Right Circumstances 3.) Right Person 4.) Right Person/Communication 5.) Right Supervision Social Relationship Goals: Socialization Goal: Mental Health trust Phases: 1. Pre-interaction – self awareness of nurses 2. Orientation – contract  do’s and don’ts 3. Working phase – identification & resolution of problems 4. Termination phase – evaluation Therapeutic Communication 1. 2. 3. 4. 5. Don’t ask why Avoid passing the buck Don’t give false reassurance Avoid nurse centered response Recognize the pt’s feelings Therapeutic

CORE CONCEPTS o o o Therapeutic phrases Open ended questions are Generally Therapeutic Closed ended effective for manic and pt’s in crisis




Direct questions for suicidal pts

Bruit = high pitched Murmur = low pitched 20/20 = Vision  attained at 3-6 years old Decorticate Flexed Adducted PlantarFlexed Extended Arms Legs Decerebrate Flexed Abducted PlantarFlexed Extended

How to attack the questions? 1. 2. 3. 4. Consider the pt’s dx Know what is normal Some conditions have inherent and expected changes in the normal values Minimal deviation from normal values are not reportable

Sodium = 135-145 Meq/L Dilutional Hyponatremia = < 120  Inc reisk for seizure = 115  Seizure Precaution Addison – Hyponatremia, Hyperkalemia Cushings – Hypernatremia, Hypokalemia Potassium = 3.5-4.5 Meq/L Normal = < 3.5  Muscle weakness Calcium = 4.5 – 5.5 Meq/L Normal = 9 – 10 mg/dl Hypercalcemia  Inc H2O intake Multiple Myeloma  Inc serum calcium level Hypoparathyroid  Dec Ca Levels in blood Thyrocalcitonin  Deposits Ca to bones Parathyroid Hormone  Bone Ca to blood Glucose = < 50  Hypoglycemia = > 140  Hyperglycemia CREATININE = .5 – 1.5 Meq/L = Best indicator for kidney function = Inc creatinine  Kidney failure BUN = 10 – 20 mg/dl = Also an indicator for kidney function = Inc BUN  Kidney failure RBC = 4.5 – 5.5 = Dec  bleeding, shock, anemia = Inc in polycythemia


= Phlebotomy  removal of 500ml of blood = Dec RBC  Activity intolerance = Inc RBC  CVA  Risk for injury WBC = 5,000 – 10,000 = Post partum  > 15,000 = Leukemia  > 150,000  Hyperleukocytosis  Risk for injury Platelets = 150,000 – 450,000 = < 150,000  Thrombocytepenic precaution = < 20,000  bleeding precaution = > 500,000  bleeding d/o = Risk for Injury PT = 11 – 12 seconds INR = 24 seconds = > 24  bleeding PTT = 60 – 70 seconds INR = 175 seconds APTT = 30 – 40 seconds INR = 100 seconds Monitored  Heparin = > INR  bleeding X 20

X 25 X 25

Hbg Female = 12 – 16 Male = 14 – 18 Newborn = 14 – 24 Pregnant = 10 – 12 = < 10  report = Results to Anemia  Activity Intolerance Hematocrit = 35 – 45 Danger of hydration = < 35  Overhydration  Fluid Volume excess = > 45  Underhydration  Fluid Volume deficit

Acid – Base Imbalance Respiratory Alkalosis Def in CO2 Hyper ventilation Hypermetabolism Hypoxia Hypotension s/sx Acidosis Excess CO2 Lung Disease Airway obstruction Resp Depression Neurological & Muscular dse s/sx Alkalosis Excess HCO3 Cushings Hypokalemia Excessive loss of acids GI vomiting s/sx Metabolic Acidosis Def HCO3 Ketone overload Lactic Acid production Kidney Disease GI disease s/sx


Restlessness Anxiety Tachycardia Syncope

Restlessness Apprehension Tachycardia Dec LOC Dec DTR

Cyanosis Hypotension Apathy Weakness

Confusion Hyponatremia Anorexia Weakness Dull H/A Kaussmaul’s breathing Mechanical ventilator

Breath thru paper bag Breath thru cupped hand

Deep breathing

Administer Ammonium Cl ABG determination Alkalosis

Acidosis Dec Dec Inc

PH  7.35 – 7.45 Hco3  22 – 26 CO2  35 – 45 HCO3  determinant for Metabolic d/o CO2  determinant for respiratory d/o RAMS = Respiratory d/o, Alternate arrow direction = Metabolic d/o, Same arrow direction

Inc Inc Dec

Compensation Compensation Uncompensated Partially compensates Fully compensated PH Abnormal Abnormal Normal Compensatory Mechanism No Change Change Change

APGAR 1 minte  Assess cardio, pulmonary and neurological status of the baby 5 minutes  adjustment to extrauterine life 10 minutes  when 2nd apgar is below 6 7 – 10  admission 4 – 6  O2 and warm 0 – 3  Resuscitation A-ppearance P-ulse G-rimace A-ctivity R-espiratory effort 0 All blue Absent No rxn Flaccid Abnormal 1 Acrocyanosis < 100 Weak cry Some flexion and extension Irregular 2 Pink > 100 Vigorous cry Spontaneous flexion & extension Lusty

Computation: 1.) D S



Vol. in cc X gtt factor # of hrs. X 60

3.) IV fluid replacement in pediatric pt Weight < 10 kg  X 100/kg 11 – 20 kg  1000ml/10kg  In excess X 50 2 kgs  1,500ml/20kg  in excess X 20 Isolation Precaution I. Standard II. Transmission Based a. Doplet b. Airborne c. Contact • HW √ √ √ √ PR X √ √ √ Mask, goggles √ (surgical) √ √(PRM) X Gloves √ X X √ Gown √ X X √

PRM (particulate Respirator Mask)


A. B. C.

Standard  AiDS, HIV, Hepa, Roseola Transmission Based: Droplet  Mumps, Mycoplasmal Pneumonia, Rubella Airborne  Measles (Rubeola), TB, Varicella Contact  Clostridium deficile, Respiratory borne, scabies, Sarcoidosis, RSV • Hepa with bowel incontinence  Contact precaution

Principles: 1. If patient goes out from the room  let the patient wear mask 2. Coherting  Same illness  Share room 3. Standard Precaution  exemption in pedia  diapered, incontinent, < 6 y/o  contact precaution HERBAL REMEDIES Saw Palmetto o Stops progression of BPH like Finasteride o Ease urinary difficulty o Interferes with iron absorption o CI: pregnancy and lactation o SE: stomach ache Blue Cohosh o Uterine tonic o Used in the last 2 – 4 weeks o To ease labor pains o Jump start stalled labor o Deliver retained placenta o Stop bleeding after delivery Black Cohosh o Sppress LH but not FSH o Relieves symptoms of menopause o Not habit forming




Does not cause cancer Limit use to 6 months  alters the normal hormonal balance

Ma-Huang o CNS Stimulant o Causes addiction o Withdrawal symptoms: depression, fatigue, irritability o With ephedra like effect o Used to treat asthma o Can cause weight loss o Not given inpatients with DM  alters the blood sugar level Chamomile o For diarrhea, anti-bacterial, anti-viral o CI: Bronchial asthma, anticoagulant therapy Cranberry o For UTI and asthma o Not for DM o Safe in pregnancy o Use with caution in DM Echinacea o Immune system stimulant o Not used for more than 14 days o Store it away from direct light o Not given in TB and chronic conditions Ginger o Anti-emetic, tx for colic and flatulence o Report bleeding and CNS depression Ginseng o Fatigue, atherosclerosis, depression, Ca o Report ginseng abuse syndrome, Diarrhea, nervousness, edema, insomnia Gingko Biloba o Improves blood circulation o Used in Alzheimer’s Disease o CI  pregnancy, lactation and clotting d/o Gotu Kova o Improves memory o For UTI, snake bites, rheumatism o CI: pregnancy, lactation and use of sedatives KAVA o Anxiety, menstrual problem, leprosy o AE: CNS depression, hepatotoxicity o Not given to pts with antipsychotic  inc sedative effects of drugs VALERIAN o Tranquilizer, sedative o Not given with valium o Uses: insomnia, mm. spasm DRUGS


Iron Supplements  FeSO4 C= Mineral Supplement  Anemia H= Relief of fatigue / Inc strength E= Best before meals, after meals if with GI irritation C= takes effect after 2-3 weeks, Inc absorption with orange juice K= Elixiform  use straw Injectable  Z track method (laterally stretch the skin, 10 seconds) SE: Constipation and black stools Antidote: Deferoxamine HCL (Desferal) RHOGAM C= Prevents RH sensitization H= ( - ) Hemolytic reaction E= 27-28 weeks AOG, ideally 72 hrs after delivery of baby with Rh (+) and ( - ) Coomb’s C= Pain in injection site K= Check Coombs test only in ( - ) OXYTOCIN Pitocin C= Induce Labor Increase force of Uterine contraction H= firmly contracted uterus E= As prescribed C= Report prolonged duration of contraction K= Avoid: Blue cohosh Check BP o o Pitocin initially causes Hypotension then rebound hypertension Methergine initially causes Hypertension then rebound Hypotension Methergine Contracts uterus after placental delivery

TOCOLYTICS C= Relaxes the uterine mm. during preterm labor H= ( - ) contractions / relaxed uterus Ritodrine HCl (Yutopar) E= Onset of preterm labor C= Report maternal tachycardia HR > 130  Arrhythmia K= Prepare antidote  Propanolol Magnesium Sulfate C= Anticonvulsant, NS depressant


H= ( - ) Seizure E= As prescribed PIH C= Report MgSO4 intoxication  Hypotension, hypocalcemia and H/A K= Check BP, urine output, RR, Patellar reflex  if Dec  antidote  Ca Gluconate Therapeutic level: o Loading dose  4 – 7 Meq/L o Maintenance  1.5 – 3 Meq/L o Depression of DTR if  8 Meq/L o Dec RR if  10 – 12 Meq/L Coagulation Process Vit K dependent clotting Factors Thromboplastin Prothrombin Coumadin Coumadin / Heparin Coumadin (Oral) C= H= E= C= K= Antidote: Lab: Heparin (Injectable) Heparin Fibrinogen  Fibrin (clot) Thrombin

Anticoagulant ( - ) Clot formation Onset: 2 – 5 days 1 -2 days Report signs of bleeding Avoid green leafy Vegetable (contains Vit K) Avoid hard bristle toothbrush Vit K Protamine Sulfate PT PTT

CHEMOTHERAPY CELL CYCLE G0 Interphase Resting G1 RNA production Alkalating Agents Anti-metabolites S DNA synthesis Antibiotic G2 RNA synthesis Plant Alkaloid Hormones Cell division Mitosis


Interferes DNA replication * CYTOXAN * MUSTARGEN

Interferes DNA & RNA Replication *METHOTREXATE (antidote: Leucoverin)


Interferes DNA synthesis *ONCOVIN

Interferes RNA synthesis *TAMOXIFEN

C= Typical

ANTI-PSYCHOTIC Atypical Anti-emetic Mania Schizophrenia Bipolar d/o Haloperidol (Haldol) Dec ( + ) symptoms (wala sa normal being) Clozapine (Clozaril) Dec ( + ) and ( - ) symptoms Apathy Alogia Avolition Anhidonia Dec dopamine levels


Hallucinations Delusion Looseness of Association

E= C= Side effects: 1.)Agranulocytosis Fever, sore throat 2.) NMS Fever, mm rigidity 3.) EPS Mm rigidity EPS = Cogentin Akineton Artane Malignant Hyperthermia = Parlodel Muscle rigidity = Dantrolene, Dantrium K=

pc = after meals Anticholinergic Tachycardia Dry mouth Blurred Vision Constipation Dec BP Side Effects: Leukopenia (<3,500 = signs of infxn) (if < 2,00 = protective isolation)

Liver Fxn Test No direct exposure to sunlight = Photosensitivity Anti-Parkinsonian at hand CI = St. John’s wort ANTI-PARKINSONIAN AGENT Dopaminergic Inc Dopamine L-Dopa Carbidopa Anticholinergic Dec Ach Congentin Benadryl



(Sinimet) H= E= C= K= C= Dec mm rigidity Dec pill rolling (after 2-3 weeks) after meals H/A, Irritability, Restlessness No to Vit B6 = dec absorption of drug Check BP and HR No CHON ANTI-ANXIETY Valium Librium = Acute alcohol withdrawal syndrome = dec tremors H= E= C= Dec center of wakefulness Before meals Dizziness Drowsiness Dry Mouth Avoid Alcohol and Caffeine Administer Valium separately = incompatible with any other drugs Avoid KAVA & VALERIAN = Inc Resp depression ANTI-DEPRESSANT SSRI ZOLOFT TCA VIVACTIL CETAVIL TOFRANIL Prevents re-absorption of Norepinephrine After meals Inc appetite Adequate sleep Initial effect = 2-3 weeks Full effect = 3-4 weeks Side effects: Dec libido Impotence K= Cardiac Arrhythmias Hypertensive Crisis Growth suppression MAOI PARNATE NARDIL MARPLAN Prevents the destruction of serotonin & Norepinephrine Stimulant RITALIN




Dec re-uptake of Serotonin

Directly stimulates the CNS

E= C=

Check the BP Avoid Citrus juices  Dec absorption of anti-depressants Observe dietary modifications Avoid St. John Wort


Avoid Tyramine containing foods: Cheddar, Swiss, Cottage and Aged cheese Cola, coffee, soy sauce C= LITHIUM ANTI-MANIC AGENTS TEGRETOL DEPAKENE (Carbamazipine) (Valproic Acid) Anti-Convulsant Alternative drug for pregnant Women Dec Hyperactivitywithin 2 – 3 weeks Acute Mania = Give Anti-Psychotic with anti-manic After meals – pc Mild 1.5 Meq/L Thirst Ataxia H/A Irritability Beginning Fine hand tremors Check signs of toxicity: Moderate 2.5 Meq/L Nausea Anorexia Vomiting Diarrhea Coarse hand tremors Abdominal Cramps Coma  Death Severe > 2.5 Meq/L

H= E= C=


Monitor Lithium Level  early morning (before breakfast) Out patient at least once a month Drug of choice for toxicity  Diamox, Mannitol CI: 1.) Pregnancy 2.) Lactation 3.) Renal Failure Dietary Modification  Inc Na (6 – 10 gm) and Inc Fluid ( 3L or more) Acute Dose: .5 – 1.5 Meq/L Maintenance: .5 – 1.2 Meq/L Elderly : not exceed 1.0 Meq/L  due to poor renal excretion

MUSCULOSKELETAL DRUGS C= H= E= Focus: Gold Therapy Suppresses Arthritis ( - ) Inflammation IM  weekly Lie supine for 10 mins to prevent OH



Check: Signs of Stomatitis Dermatitis Unusual Bleeding Unusual Bruising Fever Sore Throat Monitor Renal Function Test ANTI-INFLAMMATORY Ibuprofen (NSAID’s) Aspirin

K= C=

Anti-Inflammatory Anti-pyretic Analgesic For RA & OA H= E= C= Report: Visual disturbances Allergy Sore throat Fever Black Stool Annual eye exam Check bleeding time ANTI-GOUT AGENTS Probenecid Colchicine Acute (8-12 hrs) Prevent deposition of u.a. Anti-inflammatory Decrease uric acid Given with food NAVDA Allergy Bruising ( - ) Inflammation, ( - ) pain, ( - ) RA ( - ) fever, ( - ) platelet aggregation pc – after meals

Anti-Inflammatory Anti-pyretic Analgesic Anti-Platelet aggregate Anti-rheumatic

Ringing in the ears Nausea & Vomiting Rapid breathing Hyperpnea  toxicity



Allopurinol Chronic (1-3 weeks) Prevent formation of u.a.

Excretion of u.a. H= E= C= K=

H/A, drowsiness Agranulocytosis

Inc fluid intake 2 – 3 L/day Frequently check serum uric acid level


CARDIAC DRUGS NITRATE A. Nitroglycerine Sublingual Trans-mucosal = between gums, cheecks and lips B. Isordil Sustained release, with water and don’t crush Patch Nasal Spray C= Caridac drug (Nitrate) Dilate coronary arteries and arterioles  Dec pre-load H= E= C= ( - ) Anginal Pain Give before onset of pain 3 X at 5 mins interval After 15 mins ( + ) pain  report  May indicate MI 1. Ointment = Cover with plastic and put adhesive tape 2. Patch = Non-Hairy part 3. Oral spray = 3 sprays in 15 mins S.E. Facial flushing, H/A, Hypotension K= Rise slowly to prevent OH Tablet on dry, dark container 6 months  Discard Burning Sensation  Indication that the drug is still potent CARDIAC GLYCOSIDE Digoxin H= Strengthen Myocardial Contraction Na-K-pump is converted to Na-Ca-pump Thus increasing force of contraction Onset 5 – 20 mins Observe GI irritation C= Excreted by kidneys Normal level 14 – 26 K= Check HR = Adult 60 Older Children = 70 Infants = 90 – 110 Excreted by the liver Anti-dote: Digibive Normal level 5 -2 ug/dl Onste 30 mins – 2 hrs Digitoxin





DOPAMINE Inc force of contraction Correct Hemodynamic For Emergency Situation H= Adequate Urine Output E= Emergency Situation C= Always in diluted form K= Compute the drugs properly


C= Lidocaine (Xylocaine) For PVC’s H=

ANTI-ARRYTHMICS Quinidine Atrial Fibrillation ( - ) Arrythmia Slow ventricular rate Slow atrial rate

E= Given as prescribed C= Rash Convulsion Blurring of Vision Tinnitus/Ototoxicity

K= Check HR Evaluate ECG C= THROMBOLYTICS Streptokines TPA Dissolves the clot by preventing the formation of fibrin (fibrinolysis) ( - ) Clot formation Clot Dissolved Effective within 6 hours After MI  within 24 hrs Report Bleeding Monitor VS Contraindicated to clients that are prone to bleeding

H= E= C= K=




(HDL should be > 80 and LDL < 80) E= C= K= Before meals or at night time Caution: Hepatotoxic Questran  1 pack of powder + 4 – 6 oz of fluid (water, milk or juice) Check liver function test Rash and bleeding PERIPHERAL VASODILATOR Paracid Smooth muscle relaxant  Facilitates blood circulation H= E= C= K= C= H= E= C= K= C= ( - ) Ischemia After Meals Instruct patient that drug may cause H/A and SOB Long term use is individual BETA-BLOCKER (Timolol, Esmolol, Nadolol) Dec BP, for Hyperthyroidism, Dec sympathetic (Autonomic) nervous system stimulation Before meals Rise slowly: Lie down for 30 mins after medication. Instruct patient that meds may cause bronchospasm Do not give chamomile and aspirin ANTICHOLINERGIC Atropine Sulfate Vasolytic Agent H= E= C= K= Inc heart rate (check complete heart rate) Before meals Avoid hot environments Check for rashes and SOB NEURO-DRUGS Anticonvulsants (Dilantin) Decrease Seizure Threshold After Meals Epilepsy  Maintenance Chronis Use  Gingivitis Visit dentist at least once a year Soft bristle toothbrush, massage the gums Urine is pink tinged SAS ( Saline Flush  Administer drug  Saline Flush


C= H= E= C=



To Prevent precipitate C= Neostigmine Myasthenia Gravis Long Acting Treatment H= E= C= Short Acting Diagnostic Inc muscle strength Before Activity Before meals  Use muscles of mastication Chewing becomes stronger Medication is lifetime Report S/Sx of hepatotoxicity Check liver fxn test Keep at bedside  Neostigmine  Antidote: atropine sulfate Do not give echinicea Prepare Tracheostomy ANTI-TB Rifampicin H= E= C= K= ( - ) Infection Before Meals Red orange urine Don’t use contact lenses Peripheral Neuritis (Give B6) Oto, nephro, neuroTOXIC Hepatotoxic Psychotic like Sx INH Streptomycin Ethambutol CHOLINESTERASE Tensilon Cognex Alzeihmers Maintenance Treatment Inc mental functioning At bedtime Dec dizziness



Take the complete treatment as prescribed by the doctor ( 6 – 12 months ) Incomplete TB treatment  Lead to MDRTB

C= Theophylline Adult = 10 – 20 mg/dl Pedia = 5 – 10 mg/dl Dilates bronchioles H= E= C= K= Ease breathing In the morning  because it causes insomnia Nausea and vomiting Theophylline toxicity Check the pulse rate Avoid Chamomile  cause bronchospasm Avoid aspirin --? Cause bronchospasm

ANTI-ASTHMA Cromolyn Na Prevents anti-histamine release



Inhaler  Acute Steroid  Chronic C= H= Antidote for aspirin toxicity Dec viscosity of mucous Loose phlegm No specific time Inc OFI S.E.  bronchospasm Suction Medication has a foul odor that resemble rotten egg EMETIC Syrup of Ipecac To induce vomiting  non-corrosive Pedia below 6 months  ( - ) vomiting Dose depends on age 6 mos – 1 yr = 10ml 1 – 12 yrs = 15ml > 12 yrs = 30ml Administer with glass of water to enhance effects of ipecac Cardiotoxic = Ensure that child vomits the entire amount ANTACIDS Peptic Ulcer Disease Ranitidine 4-6 wks Dec HCl secretion Normal HCL 2 – 5 Maximum 10 H= E= C= ( - ) Pain, dec HCl Usually on an empty stomach 1 hour before meals 2 hours after meals Shake liquid SE: diarrhea Constipation Short term therapy  Electrolyte imbalance MUCOLYTICS (Mucomyst)

E= C= K=

C= H= E=

C= C=

Maalox 1-2 hrs Neutralizes HCl

Sucralfate 8 wks Coats GIT



ENDOCRINE DISEASE C= INSULIN Type 1 Regular – Humulin Intermediate – NPH Long-acting – ultra lente H= E= C= Inc transfer of glucose to cell membrane Before breakfast Report Hypoglycemia: Dizziness Dec LOC Diff. of problem solving Hypo occurs usually occurs at the peak of action of meds: Before lunch In the afternoon or before dinner In midnight or next day Rank: 4 – 8 – 12/16 Diabetes Mellitus OHA Type 2 Orinase Diabinase Metformin Pancreas to secrete insulin


C= Synthroid (supplement) For Hypothyroidism H= E= C= K= Normal BMR In morning to prevent insomnia Report signs of overdose: Insomnia, palpitation & Nervousness Life time

THYROID DRUGS PTU Tapazole ( 10 times greater than PTU) For Hyperthyroidism Dec T3 and T4, Adequate appetite and sleep Round the clock Report: Fever, sore throat, body malaise Monitor HR & BP

C= Cortisone

STEROID Floricef Replacement Therapy Addision’s Disease

H= E= C=

Correct Fluid and electrolyte Imbalance In the morning Given intramuscularly Avoid abrupt withdrawal AE: Bruising  Bone marrow depression Avoid salty foods  edema Maintain a balance diet  obesity



Avoid crowded areas  Infection C= RENAL DRUGS EPOGEN Inc RBC production  for Chronic Renal Failure Normal Hemoglobin As prescribed Report Polycythemia  Inc production of RBC  CVA Check Complete Blood Count DIURETIC Thiazide Diuretic (Hydrochlorothiazide) Duiril Distal Tubule Prevents Na absorption Increase urine output and decrease pt’s weight Early morning  prevent nocturia Hypokalemia Dec K Dec na Hypokalemia Dec K Dec Na Dec Ca Dec mg Inc Sodium in diet Check Electrolyte level Check BP IMMUNUREN (Azathioprine) C= H= E= C= Immunosuppressant ( - ) rejection of organs As prescribed Report: Nausea, vomiting Thrombocytopenia Bruising Infection Check CBC Frequent Handwashing MIOTICS (Pilocarpine) For Glaucoma Normal IOP MYDRIATICS (ATSO4) CI for Glaucoma For eye exam Dilatation of pupils Inc K Dec Na

H= E= C=

C= Loop Diuretic (Lasix)

K – Sparring Diuretic (Spirinolactone) Aldactone Blocks aldosterone Retains water

Loop of Henle Prevent Na absorption H= E= C=






E= C=

Lifetime in glaucoma Lower conjunctival sac Press inner canthus 1 – 2 mins to prevent systemic SE Check BP and Blood sugar

As prescribed Report: eye pain & blurring of vision Avoid alertness after medication


C= Vancomycin MRSA

ANTIBIOTICS Penicillin Gonorrhea Syphillis ( - ) Infection Before meals With GI irritation  After meals Ototoxic, Nephrotoxic, Neurotoxic Allergy Check I and O Peak Level = 15 – 30 mins after administration Trough level = 15 – 30 mins before the next dose Antidote: Epinephrine Given with probenecid Deep IM and check CBC Hepatotoxic Tetracycline Lymes Rocky Mountain Fever

H= E= C= K=

Guidelines on Gross Cultural Orientation and adjustment Try to get to know as much as you can about: o Social customs o Family Life o Class structure o Religion o Economics o Value System Some Areas of Culture Differences 1. Communication o Message interpretation o Personal Space o Eye contact o Touch 2. View of Time o Present oriented (Hispanics, Africans) o Future oriented (Europeans, Americans) o Past Oriented (Tribal/Traditional) 3. Family Type


o o

Nuclear Extended

4. Nutrition = kosher diet, jalal 5. Religion o Catholics o Jehova’s Witnesses o 7th day Adventist o Mormons Culture Bound Syndrome Black  Inc blood Chinese  Koro Hispanics  Pasmo Whites  Anorexia, Bullimia Death and Dying ASIANS Family and friends of same sex will prepare and wash the body MUSLIM 1. Washing of the body - women – cleanse women - men – cleanse men 2. After washing 3 time the body is wrapped in 3 pieces of clean white cloth 3. Special prayers 4. Bury the body with the head facing mecca 5. Burial of fetus = < 130 days  discard like tissue = > 130 days  proper burial rites JEHOVA’S WITNESS o Autopsy is accepted if required by law o The parts to be removed from the body o Cremation is permitted

FRAMEWORK Main Problem: SIADH  Neuroendocrine Most common / initial manifestations = SIADH  Oliguria Laboratory Data = Dec Na, Inc BP Nursing Diagnosis  Dec Na  N. Dx. Fluid and Electrolyte imbalance Priority Intervention = Dec Na  115 meq/L  Implement seizure precaution Leukemia Main Problem: Proliferation of Immature WBC Periods of remission and exacerbation Remission = Absence of s/sx  Lymphycytic  Lymphocytes  Pedia Exacerbation = Active s/sx  Myelogenous  Granulocytes  Adults S/Sx Initial: Anemia Bleeding  severe / unexplained Infection


Lab. Data:

WBC  Hyperleukocytosis  WBC 150,000

N. Dx: Priority  Safety Reverse, Isolation precaution  relative wear mask Thrombocytopenic precaution Cytotoxic Precaution Bleeding Precaution Standard Precaution HEMOPHILIA Main Problem  Inherited disorder Type A X-linked Recessive 50% male offspring ( - ) Factor 8 S/Sx: Type B X-linked recessive 50% male oofspring ( - ) factor 9 Von Willebrands disease Autosomal dominant Male & Female

Hemarthrosis  Hallmark  elbow, wrist, ankles, knees Hematoma Hematuria Hematemesis Hemmorhage

Lab Data: Clotting time N. Dx: Risk for injury, altered growth Priority: Safety Blood Transfusion, Plasma Expanded 1. Rest 2. Immobilize 3. Cold compress 4. Elevate


SICKLE CELL ANEMIA IRON DEFICIENCY ANEMIA Inc. def. of iron Dec absorption Excessive loss PERNICIOUS ANEMIA FOLIC ACID DEFICIENCY SICKLE CELL ANEMIA APLASTIC OR FANCONIS ANEMIA Pancytopenia Hemolytic THALASSEMIAS 1. Minor 2. Intermediate 3. Major Due to defect in polypeptide chains of RBC

Lack of Vit. B12 Absence of intrinsic factor In stomach: Aging  atrophy Surgery  removal

Deficiency in Folic Acid

Inherited  31Autosomal Recessive  status of Parents (See Table A.1 below) RBC C/S shape  thrombus  occlude bv Vasoclusive Crisis  due to DHN Aplastic Crisis (hemolytic anemia)  dec RBC, WBC & platelets Spleenic sequestration crisis  spleen destroys rbc rapidly S/Sx: Fever, joint pain, paralysis & weakness CVA

Baby  chubby but pale Due to over intake of milk Women  menstruation

S/Sx: 3 F’s: Fatigue, Fainting, Forgetfulness

S/Sx: 3 F’s + beefy red Tongue (glossitis) Peripheral neuritis Lab: schillings test N. Dx. Risk for injury Priority: Rest B12 supplement *Absence of beefy red tongue

Pregnant Breast feeding Infant Adolescent Alcoholic Poor feeding practice Over cooking of veggie S/Sx: 3 F’s With peripheral neuritis

Dec RBC, wbc and platelet

RBC destruction Common in blacks, Indians, Greeks, Chinese & Italians

S/Sx: 3 F’s, Inc infection, Inc bleeding

N. Dx: Activity Intolerance Priority: Bedrest, supplement Iron 2 wks, Inc iron diet  organ meats, Green leafy vegetables, dried fruits Relief of Fatigue *Desferral  Antidote

Lab: Folic Acid < 4 mg/dl N. Dx: Fatigue Injury Priority: Rest FA supplement Green Leafy veg  Spinach, broccoli  Help RBC production

Lab data: *Sickle dex test – trait *Hgb electrophoresis – Confirms the disease N. Dx: Activity Intolerance, Risk for injury, unilateral neglect Priority: Pain relief & hydration Blood transfusion  refer to geneticists

Lab Data: Dec Hgb, wbc & platelet N. Dx: Risk for injury, Infection, activity intolerance Priority: protect form infection, CBR, BT

S/Sx: Depends in types Mild: Mild anemia Intermediate: Anemia, spleenomegaly, hemosiderosis, accumulation of iron in tissues Major: severe anemia with hepatomegaly Lab Data: Dec Hgb N. Dx: Activity Intolerance Priority: Bedrest, steroids, spleenectomy


Table A.1: Autosomal Recessive Normal A. 1 parent with trait 50% B. 2 parents with trait 25% C. 1 parent with trait the 0% The other with disease D. Both parents with disease )% Neoplastic Thrombocytopenia

Trait 50& 50% 50% 0%

Disease 0% 25% 50% 100%

Purpura  Dec Platelet  due to viral infection  autoimmune reaction  drug use S/sx: Petechiae, ecchymosis, hematoma Lab Data: Platelet < 20,000, Dec Hgb N. DX: Risk for injury Priority: Safety, prevent bleeding Supplement with folic acid Blood transfusion CHD ACYANOTIC (Left to right shunting) Inc pulmonary blood flow Ventricular septal defect Atrial septal defect Patent ductus arteriousus Obstructive conditions Pulmonary stenosis Aortic stenosis Coarctation of the aorta CYANOTIC (Right to left shunting) Dec pulmonary blood flow Tetralogy of Fallot Truncus arteriosus Transposition of great vessels Tricuspid atresia Hypoplastic left heart syndrome

Risk factors: Maternal infection (14 mos) Age (> 40) Medical Condition (DM) Alcoholism Brow seating (feeding)  due to activation of ANS Baby sleeps after 3 minutes of sucking Difficulty in feeding Tachycardia Tachypnea Frequent URTI Heart Failure Retarded Growth Semi Fowlers Priority: provide warmth Initial: L sided heart failure  dyspnea & O2 & surgery Late: R sided heart failure < 2 y/o = O2 2 – 7 y/o = Surgery> 7 = Surgery as soon as possible Cyanotic (tet spell)  CVA If walking  squat If not walking  knee chest


RHEUMATIC FEVER Systemic inflammation of connective tissues (joints, CNS, heart) Risk Factors: (conditions 2-4 weeks before diagnosis) Sore throat Impetigo Scarlet Fever S/Sx: Major: Carditis  tachycardia at rest Arthritis  migratory Sub Q nodules  painless Eryythema Marginatum  rashes Chorea  Abnormal movement Minor: Fever Murmur Tachycardia

Lab: Inc ESR = Male (1-2 mm/hr, Female 20 mm/hr), Inc ASI titer N.Dx: Altered tissue perfusion, Dec CO, Pain Diet: Inc fluid intake, Inc CHON Meds: ASA, Penicillin to prevent heart valvular damage Complications: Cardiac Valvular Disease  stenosis and regurgitation Stenosis  narrowing, fusion of leaflets Regurgitataion  incomplete closure STENOSIS Mitral Dec pitch Diastolic murmur Aortic High pitch Systolic murmur REGURGITATION Mitral High pitch Systolic murmur Aortic Blowing diastolic murmur

Treatment: Antibiotics Anticoagulants Pregnant Clients Classifications: I No Limitation of activities II Symptoms with activities of daily living III Symptoms with less than ordinary ADL’s IV Symptoms even at rest

ARRYTHMIAS = Abnormal cardiac rhythm ATRIAL Flutter Fibrillation Sawtooth patter  Pwave  P:QRS ratio 2:1-4:1-6:1 Quinidine Epinephrine VENTRICULAR PVC Extra QRS Lidocaine

Fibrillation Widened QRS


Defibrillation Defibrillation CPR CPR, Quinidine QRS = < .10, 2 squares PR = .12-.20 = 35 small squares ABNORMAL CARDIAC RHYTM Heart Block  PR interval Primary  prolonged PR Interval = No intervention Secondary  Progressively prolonged PR Interval = Atropine Sulfate Tertiary  P & R wave are independent of each other = Pacemaker = HR < 5 beats below the limit = Hiccups  Failure = Belching  decreasing heart rate = Signs of shock  weak pulse = Stay away from electromagnetic field CAD o Narrowing and obstruction of coronary arteries

Defibrillation CPR

o Dec O2  Hypoxia  Angina o ( - ) O2  Neurosis
o Risk Factors: CAD Atherosclerosis Smoking Elevated Cholesterol HPN Obesity Physical inactivity Stress MI


Stable  Pattern is predictable             Anterior Wall Unstable  Pattern is unpredictable Variant (Printzmetal)  Severe form          Posterior Wall Nocturnal __> @ night Decubitus  when lying down             Lateral Wall Intractable  Unresponsive to treatment Post MI  After MI Pain < 20 min Upper sternum Pressure Relieved by rest Nitroglycerine Precipitates: Eating Elimination Extreme temp Emotion Effort Associated S/sx: Pain > 20 min Lower sternum Crushing, Excruciating Not relieved by rest Morphine (Check RR)  Antidote  Naloxone


Agitation Restlessness Cold clammy skin HPN

Lab Data: Inc cholesterol < 200 ECG changes N. Dx: Pain Position in Semi Fowlers Administer drugs as ordered Diet: Cholesterol restricted diet Percutaneous Transluminal CardioAngioplasty

Inc cardiac enzymes Inc ST segment Inc ESR

= Done if 50% of blood supply to heart is impended = Insertion of a balloon tipped catheter  ballooning  cardiac stent Coronary Artery Bypass Graft = Done if 50% of blood supply to heart is impended = Placing a new blood vessel Health Teaching: o Avoid strenuous activities o Can resume sexual activity  if can climb 2 – 3 flights of stairs with no dyspnea o Provide frequent rest periods o Discharge Instructions  Avoid life threatening conditions HEART FAILURE = Inability of the heart to pump adequate amount of blood to meet the metabolic demand of the body. Risk Factors: MI Heart valvular disease RHD HPN Arrhythmia S/Sx: Left sided: Dyspnea, pink sputum, productive cough, pulmonary edema Right sided: Distended neck veins, ascites, ankle edema, hepatomegaly Lab Data: Left cardiac function  Swan Ganz Right Cardiac Function  CVP N. Dx: Altered tissue perfusion and dec CO Priority: To Inc CO


Position in semi fowlers Administer drugs as prescribed  Digitalis, Vasodilators, Diuretics *Morphine  dec venous return to the heart  peripheral vasodilating effects Diet  Low Na, Low Cholesterol Assess breath sounds, edema, heart sounds HYPERTENSION = Silent Killer disease Hypertensive disorders of pregnancy = Persistent elevation of BP above 140/90 = 120/80  Pre-hypertensive = 110/70  normal Risk Factors: Family Hx Age Blacks Obesity Stress Smoking Types: 1.) Essential  Unknown 2.) Benign  Unknown / Long duration 3.) Malignant  Acute, short duration 4.) Secondary --? Due to medical condition Complications: Occipital HA Retinal Hemorrhage Pedal Edema 4 common complications: CAD CVA CRF CHF

Lab: Inc in cholesterol, Inc LDL, Inc TAG N. Dx: Altered health maintenance  Tx is prolonged = Vasodilator, Anti-lipemic agents * Common cause of concern  Bronchospasm, Dec libido Diet  Dec Na, Dec cholesterol NON-PHARMACOLOGIC REGIMEN Stress Mx: Exercise  deep breathing, walking, stress free hobbies (like walking by the bay) HPN in pregnancy  Unknown = Generalized vasospasm  due to virus  H. Lualba = 2nd trimester = B4 20 wks AOG  H. Mole / GTD = after 20 wks AOG  PIH = Before and after pregnancy  chronic hypertension HYPERTENSIVE D/O OF PREGNANCY o Inc BP


PRE-ECLAMPSIA o Inc BP o Edema o Proteinuria: Mild : BP  140/90 Protein  < 5gm/24hrs Severe: BP  160/110 & above Protein  > 5 gm/24hrs o Mx: Darkened room Inc CHON diet MgSO4: Antidote --> Ca Gluconate ECLAMPSIA o Inc BP o Edema o Proteinuria o Convulsion  bleeding  HELLP Syndrome (hemolysis, elevated liver enzyme, low platelet  manifested with petechiae PVD

Color Edema Nails Pain Pulse Temperature Ulcer BUERGER’S (Thromboantgitis Obliterans) - Acute -A&V - Male - Lower ex - Smoking - Inflammation of arteries and veins

Arterial Occlusion Pallor ( - ) or minimal Thick & brittle *Intermittent Claudication (-) Cold Dry RAYNAUD’S DISEASE - Intermittent - arteries - Female - Upper ex (97%) toes, ears, LE (3%) - Cold - Vasospasm of arteries

Venous Occlusion Ruddy Severe Normal Homan’s sign Normal Warm Wet ARTERIOSCLEROSIS OBLITERANS - Chronic - arteries - Male - Upper & Lower ex - hardening arteries

Pain Intermittent Claudication – Intermittent color changes (Pallor, Cyanosis, Redness) Lab data: Painless Doppler UTZ N. Dx: Pain & altered tissue perfusion Priority: Anti HPN, Vasodilator, Anticoagulants Instructions: Avoid smoking, swimming in cold water


PULMONARY EMBOLISM - A clot lodges in one of the pulmonary arteries Risk Factors:

1.) VA  Trauma
2.) Hypercoagulation 3.) Arrhythmia 4.) Thombosis S/Sx: Anxiety / Agitation Dyspnea Restlessness Tachycardia Tachypnea Chest Pain *Crackles Lab Data: Perfusion Lung Scan N. Dx: Pain, Ineffective breathing pattern Priority: Positioning Right sidelying Administer Anticoagulant ABDOMINAL AORTIC ANEURYSM - Weakening of the walls of the aorta - Congenital - Angina - Chronic HPN Types: 1.) Fusiform – bulging of both sides of bv 2.) Disecting – Dissected inner wall of bv 3.) Saccular – forms a pouch or sac S/Sx: Assymptomatic Pulsating Abdominal mass Low Back Pain Inc BP of Ue, Dec BP in LE Lab data: Aortography, X-Ray N. Dx: Risk Poor injury  altered tissue perfusion Safety  Most Abdominal Palpation Prepare pt for surgery that will involve grafting After surgery  assess for distal pulses KAWASAKI’S DISEASE - Acute systemic inflammation of the vascular system - Heart & blood Vessels - Common in Japanese, toddler & pre-schooler - Unknown S/Sx: High spiking fever for 5 days of more Strawberru tongue, palmar desquamation


Lab Data: 2 D-Echo, ECG N. Dx: Altered tissue perfusion, Dec Cardiac output Priority: Tx is supportive, ASA Diet: Clear Liquid Discharge Infection: Teach Pt. CPR 5:1  Pedia 15:2  Adult 30:2 1. To Assess risk of developing mitral valve stenosis in pt. What should the nurse ask the pt? A: Did you have streptococcal infection 2. How to assess intermittent Claudication: A: Ask the pt to walk and note presence of pain 3. What should the nurse prepare at bedside with PVC A: Xylocaine 4. Priority in pt with complete heart block A: Altered tissue perfusion 5. Goal of Care with atrial fibrillation A: Inc CO 6. Coomon complication of sickle cell anemia? A: CVA 7. Signs of left sided heart failure A: Dyspnea on excretion 8. When planning an exercise program in pt with HPN, Nurse should ask? A: How do you spend your leisure time CYSTIC FIBROSIS - Inherited multi system disease affecting the exocrine gland - Autosomal recessive  each pregnancy  (Disease 25%, trait 50%) - Excessive Mucous production  Made = Sterility, Female = Diff. in concerning S/Sx: Initial: Abdominal distention Malabsorption Syndrome  Steatorrhea  Foul smelling fatty, stool Salty when kissed Lab: Pilocarpine Sweat test Respiratory Therapy: Blowing Exercise  Trumpet  Blowing Bubbles GI Therapy: Pancreatic Enzyme  Pancreas  Viokase  with each meal & snacks Refer pt’s prevents  geneticist Pt. Grows  OB PNEUMONIA - Mycoplasma Pneumonia (pedia), Legionnaires disease (elderly, alcoholic, immunosuppresion) - Inflammation  Allveoli  Exudate, Consolidation - Viral, Bacterial, Rickettsia S/Sx: 5 Cardinal signs & symptoms 1. Fever 2. Sputum 3. Pleuritic Chest Pain 4. Chills 5. Cough



Low grade fever Thin & watery sputum WBC either normal or slightly increased

Bacterial - High grade fever - Rusty sputum - WBC severely increased Lab data: Chest X-ray, sputum exam, ABG analysis N. Dx: Impaired Gas Exchange Ineffective Airway clearance Ineffective Breathing pattern Priority: Bed Rest, Inc OFI, Administer meds as ordered: antibiotics CROUP ACUTE LARYNGITIS Toddler Larynx S/Sx: Cough: Barking, metallic Stridor: Present Wheezing: Absent Fever: Absent Lab Data: Throat Swab PE X-ray N. Dx: Infection, Ineffective breathing pattern Priority: Tx of infection Multi-drug therapy OPD (Obstructive Pulmonary Disease) Narrowing and obstruction of the airway Emphysema Bronchitis Asthma LTB Infant & toddler Viral & Bacterial Inflammation of the Larynx and trachea Harsh & Brasky Present Absent Low Grade X-ray Throat swab PE BRONCHIOLITIS Infant < 6 mos (RSV) Bronchioles Paroxysmal & Hacking Present Present Moderate to high grade X-ray ELISA Throat swab PE


-overdistended alveoli

- inflammation of bronchioles Smoking RE,TACY,TACHY DC

-excessive mucus

Barrel Chest Lab Data: X-ray, ABG Analysis N. Dx: Ineffective Breathing Pattern Ineffective Airway Clearance Orthopneic Semi-Fowlers Principles in Nursing Care: Bronchodilator Rest Oxygen low flow Nebulize Chest Physiotherapy High Fowlers IPPB – Intermittent Positive Pressure Breathing Aerosol Liberal Fluid Intake Complication: Cor Pulmonale Right Ventricular Hypertrophy

Gelatinous Sputum Inc coughing

Whitish sputum Orthopnea


Activity: Soft ball Baseball

Aminophylline Steroid Theophylline Histamine Antagonist Mucolytic Antabuse

Pneumothorax Spontaneous Ruptured Bullae/alveoli Open Chest injury Tension Trauma

Increase tension and pressure Thoracic cavity Lung collapse ( - ) breath sounds Dyspnea Pain 3 way bottle sys Pointers for Respiratory:

1.) Mist  Priority?
A: Change the linen and clothing to keep the pt dry. 2.) Goal of care for child with bronchiolitis? A: Minimize O2 expenditure 3.) Pancrease is given with meal 4.) Patient with TB  What is the purpose of NGT?


A: To aspirate swallowed sputum 5.) S/Sx that indicates emphysema? A: Barrel shaped chest 6.) Development of Edema? A: Moist and noisy breathing 7.) Common risk factor for Legionnaire’s disease? A: Immunosuppression 8.) Mycoplasmal Pneumonia is manifested by? A: Fever & productive cough PKU

o Inherited disorder characterized by absence of phenylalanine hydroxylase (PH) which converts phenylalanine
o o o to tyrosine (precursor)  melanin for hair, eyes, skin Normal level = 2mg/dl, 4mg may indicate PKU, 8mg confirms PKU Autosomal recessive Phenylalanin is toxic to the brain and causes MR

S/Sx: Asymptomatic at birth: Diarrhea, Anorexia, Lethargy, Anemia, skin rashes N. Dx: Knowledge deficit Altered nutrition Risk for injury  seizure Health Teachings: Low Phenylalanine  up to adolescence  9-10 y/o Refer to Geneticists and nutritionist Produce list of foods that’s is allowed and not allowed


o o


Congenital deficiency in T3 and T4 S/sx  Asymptomatic  maternal hormonal transfer 2 – 3 mos s/sx appear Behavioral: Apathy, well behaved baby Physical: Large tongue, short structure, retarded growth  MR

Lab data: Dec T3 and T4 N. Dx: Knowledge deficit Risk for activity intolerance Altered growth & development Priority: Administer Synthroid, single morning dose forever Report: Tachycardia (palpitations) Insomnia Nervousness *Provide warm environment * Refer to special education center PANCREAS ALPHA CELLS Glucagon BETA CELLS Insulin

MODY (Maturity onset Diabetes in young adults)

Absence IDDM (Type I)

Deficiency NIDDM (Type II)


Combination of IDDM & NIDDM Pregnancy 2nd trimester Developed placenta secretes HPL (Human placental lactogel  counteracts insulin Gestational: (White’s classification) Types: A: Chemical DM: B: onset: >20 y/o C: 10 – 19 y/o D: < 10 y/o D1: < 10 y/o D2: > 20 y/o D3: Beginning retinopathy D4: Hardening arteries D5: HPN E: Pelvic arteries F: Retinopathy H: Cardiopathy R: Retinopathy T: Transplant kidney

Juvenile onset Ketosis prone Thin

Maturity onset after 35 Non Ketosis form Obese

- Absence or deficiency in insulin affects, CHO, Fats & CHON metabolism - Insulin facilitates entry of glucose into the cell - If there is no insulin  glucose remains outside the cell  hyperglycemia  fluids are attracted to cell & blood - Cells dehydrated (brain)  compensatory mechanism  Polydipsia - Cells dehydrated (brain)  Inc glomerular filtration rate  Poly uria  leads to weight loss  cell stones  brain  polyphagia Lab Data: FBS, Glycosylated Hgb, Hemogluco test N. Dx: Knowledge deficit Altered Nutrition Altered Elimination Risk for Infection Priority: To maintain normal blood sugar Diet: 50 -70 % CHO, 20 – 30% Fats, 10 – 20% CHON Well balanced diet Insulin: Type I, pregnant 2nd trimester  Inc dose Anti-Diabetic Agents  sulfonylreas  CI --> sulfa Drugs Blood sugar  am and pm Ensure Adequate food intake Transplant of pancreatic cells Exercise  Moderate Scrupulous Foot care  Avoid barefoot, avoid synthetic shoes  Indicated: Foot powder, snuggly fitting shoes, cotton socks, visit podiatrist atleast once a year Complications: Hypoglycemia: Blood Sugar  < 150mg/dl RF: too much insulin, missed meal, exercise S/Sx: Diaphoresis Decreased LOC Diff in problem solving Hyperglycemia: Blood sugar  > 140mg/dl RF: Too little insulin, Inc food intake, pregnancy, Infection, stress, surgery Type I DKA Acetone breath De H2O Warm skin type II HHNK Inc GI s/sx DeH2O Inc serum Osmolality


Tx: Simple sugar

3 P’s 3 P’s Kussmauls breathing TX: Airway, Fluid and Insulin  rapid acting insulin

Other Complications: 1.) Microangiography  damage to small retinal blood vessels 2.) Atherosclerosis  hardening of arteries  HPN 3.) Neuropathy  Kidney damage 4.) Retinopathy  Opthalmopathy  damage to nerves 5.) Peripheral / Autonomic  Dec nerve impulse transmission

PITUITARY GLAND ADH Fluid Retention Deficiency Diabetes Insipidus Risk Factor S/sx: Lab Data: Trauma Surgery Polyuria (21L/day) Polydipsia Fluid deprivation test NPO X 12 hrs Concentrated urine Specific Gravity: < 1.005 Check specific Gravity Exercise SIADH Trauma Tumor

Vasopressin Depressin Lepressin Monitor and output and specific gravity of urine Goal of care: Excretion of fluid  Diuretics and anti-HPN Growth Hormone Ant. Pituitary Gland Promotes growth Deficiency Dwarfism  Mahal Achondroplasia  “Nanus Syndrome”  Dagul

Fluid retention Dilutional Hyponatremia Check Sodium

Excess *Before closure of growth plate  Gigantism  Taller, slender  Marfans’ Syndrome  Genetic d/o, a. Dominant  spine d/o  Scoliosis  Cardiac problem *After closure of growth plate  Acromegally  enlargement of Extremities * Inc growth hormone and glucose ADRENAL

Outer Cortex

Middle Medulla


Glucocorticoids Gluconeogenesis Def. Addison’s

Mineralocorticoids Na retention Excess Cushings Excess Conn’s Syndrome Commons syndrome  Aldosteronism

Epinephrine Nor-epinephrine fight/flight response Tumor Pheochromocytoma  excess epi and norepinephrine HPN, H/A Inc hyperglycemia Hypermetabolism

Lab Data: Inc VMA  2 – 7 mg/dl in 24 hrs Avoid vanilla containing foods, 14 hrs before the test

ADDISON’S Deficiency Glucocorticoids Mineralocoticoids RF: Autoimmune Surgery S/Sx: Hypoglycemia Hyponatremia Hyperkalemia Hypotension – shock like Brown skin pigmentation Truncal Obesity Mood swings Facial hirsutism Buffalo hump Moon Facie Glucocorticoids

CUSHING’S Excess Mineralocoticoids Tumor Hyperglycemia Hypernatremia Hypertension Truncal Obesity Mood swings Facial hirsutism Buffalo hump Moon Facie

CONN’S Excess Mineralocoticoids tumor Hypertesnsion Hypernatremia Hypertension Truncal Obesity Mood swings Facial hirsutism Buffalo hump Moon Facie inc Na & dec K, Inc BP Anti-HPN Diuretics Dec Na, Inc K

Maintain Fluid and electrolyte Balance Steroids steroids inhibitor *Fludrocotisone Florinef Mitotaine Dec s/sx: Normal Na and blood sugar Diet: Inc Na, Dec K Dec Na, Inc K Client Teachings: Meds for life Prone to osteoporosis Avoid crowded areas Excessive poor wound healing

THYROID T3, T4 BMR Deficiency Hypothyroidism - Cretinism - Myxedema RF: Autoimmune, tumor Excess Hyperthyroidism - Grave’s disease - Basedow’s disease - Parry’s disease CALCITONIN Deposition of Ca in the bones


S/Sx: Facial edema Intolerance to cold Hypometabolism Lab Data: Dec T3, T4, Inc TSH - Activity intolerance -Uthyroid state  Normal - Give thyroid supplement - Synthroid SE: - Insomnia - Nervousness - Palpitation Diet: - Dec Calories - Warm environment THYROID SURGERY Preparation

Exopthalmos Goiter Hypermetabolism Intolerance to cold Inc T3, T4, Dec TSH - Risk for injury - Uthyroid state - Anti thyroid drugs - Propylthiouracil - Agranulocytosis (Fever, Soar throat) - Inc Calories - Cold environment

Post operative - Monitor complication 1. Hemmorrhage – bruises 2. Laryngospasm – tracheostomy 3. Damage to laryngeal – inability to speak, aphonia 4. Tetany – Dec in Ca > Tingling, chvostek, Trouseau sign 5. Thyroid crisis Complications: Fever, Inc HR, check VS

- Lugol’s solution (2 wks before surgery) - Dec size & vascularity of thyroid gland - Give in straw and diluted in water or apple juice - S/sx of iodism  Metallic taste

PARATHYROID - Inc Ca in the blood Hypothyroidism Surgery S/Sx; Early: Tingling, chvostek, Trouseau sign N. Dx: Risk for injury - Give Ca supplements - Inc Ca in diet Renal calculi formation Lab Data: Inc Ca in blood N. Dx: Risk for injury Priority: Surgery Mx: Inc OFI Hyperthyroidism Tumor - Pain, bone destruction, fracture / osteoporosis - Von Recklinghausen disease

Pointers: 1. Manifestations of Ketoacidosis: A: Rapid and deep breathing 2. Post thyroidectomy  Tetany of hands, feet and muscle twitching, the nurse knows the doctor would order? A: Ca Gluconate 3. W/c of the ff. indicates hypothyroidism? A: Intolerance to cold 4. In PKU, which is not indicated? A: Milk Shake


5. Which of the ff. manifestation indicates a complication post thyroidectomy? A: Tachycardia 6. Which of the ff. interventions is appropriate for a pt with Addison’s disease? A: Monitor the BP 7. Insulin was given at 8 am, when do you expect hypoglycemia? A: Before lunch 8. In PTU an expected outcome is a? A: Dec in PR 9. Hypothyroidism  best question? A: Do you tire? 10. Which of the ff. data needs to be assured in head injury? A: Dec urine specific Gravity

NEPHROTIC SYNDROME Congenital Autoimmune - Inability of the kidneys to maintain fluid balance *hyponatremia S/Sx: - Normal or dec in BP - Peripheral Edema subsides at the end of the day - Frothy urine color

ACUTE GLOMERULONEPHRITIS Acquired  sore throat Autoimmune - Kidney damage

- Inc BP - Progressive peripheral edema at the end of the day - tea colored urine / cola

Lab Data: - Most significant data  Proteinuria = > 10mg/24hrs - Proteinuria = < 10mg/24hrs - ( - ) Colloid osmotic pressure  edema - Inc ASOT N.Dx: - Fluid Volume excess - Risk for impaired skin integrity Mx: - Goal of care  promote fluid balance - Restricted fluid - Frequently turn client - Steroids - AGN: Anti-HPN - Dec Na, Inc CHON - Dec Na, Dec CHON

WILM’S TUMOR - Congenital tumor of kidneys - unilateral left kidney - palpable on abdomen - common in children < 5y/o - ( + ) HPN, Hematuria - Risk for injury - Promote Safety - Prepare pt for surgery & chemotherapy - Avoid abdominal palpation CYSTITIS - Ascending infection


- Bladder  Ureters  Kidneys  pyelonephritis  CVA tendency RF: - bubble bath - Silk underwear - Prolonged driving - Catheterization S/Sx: - Burning sensation Lab Data: - Urinalysis - Inc WBC - Inc glucose Tx: - Treat infection - antibiotics - Acid ash diet - Inc OFI - Avoid risk factors RENAL FAILURE ACUTE - Sudden cessation of kidney function RF: PreRenal -Dec circulation of Blood volume S/sx; Oliguric Phase -Dec urine output - < 400ml IntraRenal -disease of kidney PostRenal - obstruction -stone Recovery Phase - 1-2 yrs CHRONIC - Progressive/ irreversible destruction of kidney tissues - Scar formation - AGN, NS

Diuretic Phase -polyuria, dec Na & K

1. Dec renal reserve – polyuria, nocturia, polydipsia 2. Renal insufficiency – Inc BUN & creatinine 3. Renal Failure – HPN, Renal Damage 4. ESRD – Azotemia, uremia Lab Data: - Inc BUN & Crea N. Dx: - Fluid & electrolyte imbalance Priority: Fluid restrictions Meds: Epogen to prevent anemia - Amphogel – prevent hyper phosphatemia - Diuretics, Anti-HPN, Digitalis Diet: Dec Chon Mx: Dialysis: 3 X a week or every 48 hours

N. Dx: - Fluid & electrolyte imbalance Priority: Restore circulating fluids - Monitor intake and output - Response of client on therapy – output, BP Meds: Diuretics, Dec Na diet, Anti-HPN, digoxin

DIALYSIS Hemodialysis Dialyzing agent - Dialyzing Machine Access Fistula shunt -internal access - external access -anastomisis of a & v - palpate for thrills and auscultate bruit Complications Peritoneal - Dialyzing agent – Peritoneum Access - Ten khoff catheter - assess rigid abdomen  peritonitis


Disequilibrium Rapid removal of waste product Fluids and electrolytes GI CNS NAVDA H/A Dizziness Restlessness - Report to MD

Dialysis Encephalopathy -Aluminum toxicity -S/Sx: dementia, dizziness -Report to MD

BPH - Glandular enlargement of the prostate - After age 40, male S/Sx: - Dec size & force of urinary stream - Nocturia - Dysuria - Frequency, urgency, hesitancy Lab Data: DRE  @ age 40 Priority: Promote Urinary elimination  Prepare for surgery TURP  no incision Suprapubic Retropubic -above the bladder -below the bladder

Perineal -causes impotence

Pointers 1. An elderly with oliguria and flank pain may indicate a problems caused by? A: Intake of neomycin 2. Which laboratory data needs to be reported? A: urine specific gravity of 1.004 3. 12 hrs after TURP – the pt complains of spasm A: Check patency of retention catheter. 4. A 2 y/o boy with Nephrotic Syndrome with periorbital edema & frontal edema what will be the essential nursing measure: A: turn pt frequently 5. Which of the ff is a common complication of chronic renal failure? A: Anemia 6. A pt with Nephrotic Syndrome asks “Why am I gaining weight?” the best reponse is? A: you have sodium retention that attracts water 7. During hemolysis, pt with HA and vomiting, restless and confused, he is having? A: Disequilibrium syndrome 8. After peritoneal dialysis the return flow with dialyzate solution is inadequate, What should the nurse do? A: Turn pt from side to side. 9. A Priority N. dx to a pt with renal stones? A: Pain

OTITIS MEDIA - Infection of middle ear - URTI - Faulty feeding


- swimming in dirty waters - Pain, fever, earache Lab Data: PE, otoscope, bulging tympanic membrane N. Dx: Pain  antibiotic, decongestant, Pseudafed Chronic: myringotomy tube insertion RETINAL DETECHMENT o Separation o Sensory pigment  retina o Aging  40 y/o o Trauma o S/sx: visual floaters  painless Cobwebs, veil like, floating spots o Lab Data: Opthalmoscopy, PE o N. Dx: Risk for injury o Priority: Safety, bedrest, affected side towards the bed o Scleral buckling  using laser to create a scar o Avoid sudden head movement, bending and blowing of nose o Surgery: Trabeculoplasty  trabecular meshwork  laser  out pt Ttrabeculectomy  trabecular meshwork  removal  in pt for 1 -2 days o Avoid bending and sudden eye movement o Report: eye pain and bleeding GLAUCOMA o Inc IOP o Open Angle: Chronic  Inc aqueous humor o Closed Angle: Acute  forward displacement of iris o Aging > 40 y/o o Familial o “tunnel vision” o “Gun barrel vision” o “halos around lights” o “Loss of peripheral vision” o Blindness o Lab Data: Tonometry, (gonioscopy  differentiate open from closed angle glaucoma), perimetry -> visual fields o N. Dx: risk for injury, safety, dec IOP o Meds: Myotics  pilocarpine o CI: Midriatics CATARACT o Opacity of lenses o Poor color perception o Painless o Aging > 40 y/o o Prolonged steroids o Lab Data: Opthalmoscopy  ( - ) red light reflex o N. Dx: Risk for injury o Surgery: Peripheral iridectomy  hole in lens  cataract is suctioned Photoemulsification  needle like structure inserted into the lens -> crush cataract o Avoid bending and sudden eye movement o Report: eye pain and bleeding


MENIERE’S DISEASE - Imbalance in the endolymphatic fluids - inner ear - RF: -High altitudes (pilots and divers) - s/sx: -Hearing loss -Tinnitus -Vertigo – revolving motion - Lab Data: - Caloric stimulation test - N. Dx: - Risk for injury - Intervention: - Safety - Position  supine or flat - Diet: Low Na - CI: Streptomycin  ototoxic - Meds: DIAMOX Pointers:

OTOSCLEROSIS - Hardening of the bones in the inner ear - affected  stapes -Aging -diff in communicating -tinnitus -conductive hearing loss - Weber and Rhine’s test - Impaired communication - establish communication - stapedectomy  mobilize stapes - post surgery: avoid blowing of nose - avoid deep diving - avoid flying in small airplanes

1. Post trabeculoplasty  eye pain. A: Call MD 2. Pt with tunnel vision, N. Dx? A: Inc risk for injury 3. Which drug will help dec aqueous humor? A: DIAMOX 4. Post Cataract extraction, what is the position? A: On unaffected side to dec edema 5. Which intervention will help prevent loss of vision in glaucoma? A: Taking the meds correctly as ordered 6. Which describes trabeculoplasty? A: Surgical intervention that aims to create a passageway for the blocked fluid.

DUCHENNE’S MUSCULAR DYSTROPHY - genetically transmitted - X-linked recessive (mother to son – 50% disease, Mother to daughter – 25% trait) S/sx: - Gower’s sign  arms used to push body to stand up - Waddling gait - Difficulty in running and climbing  1 ½ to 2 ½ - Progressive weakness  respiratory paralysis - Lab Data: EMG, PE N. Dx: Ineffective breathing pattern Impaired physical mobility - Prepare tracheostomy set - Refer parents to geneticists - refer to PT - Treat symptoms CEREBRAL PALSY

ERB DUCHENNE PARALYSIS - acquired - Birth trauma (hyperextension of shoulder) - Brachial Plexus – upper plexus - Reversible, recovery after 3 mos - Klumpke’s paralysis – lower plexus


- non- progressive (fixed) d/o - neuromuscular system - uncoordinated movements - related to brain anoxia and prolonged labor S/sx: - Exaggerated reflexes - Early pattern of hand dominance  10 – 12 months - poor posture - Arching of back - Frequent tongue thrusting - scissor gait Lab Data: - CT Scan - Muscle biopsy N. Dx: - Risk for injury - Improved Physical integrity - Altered nutrition Priority: Promote Safety & mobility Assist ambulation Support: crutches, cane, walker, leg braces - Drugs – muscle relaxants, anti-convulsants - Surgery – release of tendon of Achilles - Foods that sticks on spoon CSF FLOW Lateral Ventricles  Foramen of Monroe  3rd Ventricle  Aqueduct of Sylvius  Foramen of Lushka & Magendie  4th Ventricle  Sub-arachnoid spaces HYDROCEPHALUS - Interruption of CSF flow - Not a disease - Manifestation  d/o - Arnold Chiari Malformation  Elongation of brainstem  Obstructs the flow of CSF - Dandy Walker  atresia  narrowing of foramen of Lushka & Magendie  CSF flow - Excessive production (communicating) or obstruction of CSF (non-communicating) S/Sx: Projectile vomiting, irritability, enlarged head (Normal  33-35 cm), Sunset eyes, separation of sutures, seizure) Bossing sign  pronounced forehead Macewen’s sign  cracked pot percussion of head Lab data: CT Scan, MRI N. Dx: Risk for injury Priority: Safety, Seizure precaution Meds: Anti-convulsants Position: Semi-Fowlers Low-fowlers Surgery: Insertion of ventriculoperitoneal shunt - Check  Inc in ICP - Measure head frequently SPINA BIFIDA - Failure of spinal processes to fuse - neural tube defects - Occulta: Dimpling, tuff of hair, lumbo-sacral area - Cystica: Meningocel  CSF & meniges, Myelomeningocele  CSF, meninges, spinal cord


Lab Data: PE, MRI Alpha Feto CHON analysis  Increased Normal  15 – 30 N. Dx: Risk for infection, Impaired mobility - Sidelying or prone  best position - Cover with wet sterile gauze - Surgery  within 48hrs  prevent paralysis of LE  After sac is closed  may lead to hydrocephalus - Tape measure  @ bedside to measure head

Increase ICP - ICP more than 15mmHg -Normal 0 – 10 - 11 – 20  mild - 21 – 30  moderate - 31 and above  severe - Maybe due to trauma - Space occupying lesion - A congenital defect S/Sx: Early: Decreasing LOC Late: VS changes, Cushing’s triad, widened PP, Dec PR, Dec RR Lab Data: Subdural / intravascular monitoring N. Dx: Risk for injury Priority: Safety, head of bed elevated, evaluate LOC, promote a patent airway Discharge instutions: meds, mitoring, seizure precaution BACTERIAL MENIGITIS - Infections  inflammation with menigitis - N. Menigitides - Influenze Virus - HIB Vaccine S/Sx: Inc ICP, Brudzinski’s sign, Kernig’s sign Lab Data: CSF, Dec Sugar, Inc WBC, Inc Protein N Dx: Risk for injury, Risk for injection Meds: Antibiotics as prescribed Precaution: Respiratory Droplet Complication: Hearing Impairment Audiologist Screening and testing REYES SYNDROME - Toxic - Encephalopathy & Hepatopathy - Fatty infiltration - CNS and Liver - V. Vax related to Reye’s - Triad Symptoms: Fever, Dec LOC, Bleeding tendencies Stages: 1.) Stage 1 = Confused 2.) Stage 2 = Lehargic 3.) Stage 3 = Decorticate 4.) Stage 4 = Decerebrate 5.) Stage 5 = Comma Diagnostic: Biliary fxn test, bleeding time, clotting time, Neuro assessment GCS N Dx: Risk for injury


Priority: Safety  Bleeding precaution, clotting time, Neuro-assessment GCS  Vivax ( + ) chickenpox  Reye’s SEIZURE - Abnormal discharge of electrical impulse in the brain RF: Metabolic d/o  Delirium Alcoholism  withdrawal symptoms Intake of drugs & trauma S/Sx: Types 1.) Absence / petitmal  brief periods of non-activity 2.) Jacksonian  Starts on body parts  to whole body 3.) Grandmal  Tonic: gen. contractions, Clonic: alternating contraction & relaxation S/Sx: Dura  feeling of uneasiness before seizure and LOC and convulsion. N. Dx: Ineffective Airway Clearance Risk for injury Smal pillow at the back of head or lap Meds: Anti-convulsants, Dilantin - Refer to Neorologist - Subs. Abuse screening - EEG, MRI, CT Scan Precaution: Avoid extremes Avoid emotional stress Lifetime anti-convulsants CVA - Sudden cessation of brain functions due to dec O2 RF: Thrombosis, embolism, hemorrhage & infarction Progression: 1.) TIA  brief neurologic deficits  30 secs  24 hrs 2.) Stroke in evolution  body weakness / facial weakness 3.) Completed stroke Frontal Lobe  personality, speech changes  Broca’s aphasia  Expressive Aphasia  Inability to say the right words Temporal  Memory, Wernicke’s Aphasia  Inability to comprehend Parietal Lobe  sensation & orientation Occipital  Visual disturbance S/Sx: Indicative of Complication Hemiplegia  Paralysis of right or left side of body Homonymous Hemianopsia Emotional Lability  Mood swings Aphasia  Expressive and receptive Dysphagia  Swallow food at least twice - C4-C5 deccusation of spinal cord - Right lesion  Left eye, right face , Left body affectation  Unilateral Neglect Lab Data: Inc cholesterol  Normal 200 EEG, MRI, CT-scan N.Dx: Ineffective breathing pattern - Head of bed elevated - Refer to PT & OT Diet: Low Na, Low Fat Meds: Anti-convulsants, vasodilator, diuretics



GBS PNS - Inflammation & destruction of PNS - Autoimmune  viral infection - No gender related factors NMJ



ALS (Lou-Gehrig) Upper & Lower Motor Neuron - Autosomal dominant - Male & Female

- Autoimmune (early – male 20 – 40 y/o, late – female > 50 y/o) - Deficiency in acetylcholine receptor sites - descending muscle weakness -from face downward - Ptosis - Difficulty in chewing - Decrease voice CI: Talking long  respiratory depression Diagnostic: Tensilon  short 30 secs  lasts for 5 mins Drugs: Neostigmine  lifetime  Antidote  ATSO4

- Whites/females - Demyelination of neurons in CNS - Brain and Spinal Cord

S/Sx: - Ascending or descending muscle paralysis - Mixture - Respiratory Depression - Lab. CSF Analysis  Inc CHON N.Dx: - Ineffective breathing pattern Priority: - Promote patent airway

- Prepare tracheotomy set @ bedside - steroids - Refer to Respiratory Therapist

Complications: - Crisis - Myesthenic: Dec Meds  Neostigmine - Cholinergic: Inc Meds  ATSO4

- Diplopia - Ptosis - Impaired sensation - Impaired sexual function - General muscle paralysis Lab: MRI, localizes areas of plaque formation N.Dx: - Ineffective breathing pattern - Sensory perceptual alteration Priority: - Maintain patent airway Meds: - steroids - Muscle relaxants - Bladder stimulant - Avoid hot or cold shower - Assist diet in ambulation * Bladder retraining program – self catheterization - Handwashing  to prevent ascending infection -Refer to PT & OT

- Dysphagia

Lab: EMG, CT Scan, MRI N.Dx: Ineffective breathing pattern Priority: - Airway - Prepare tracheostomy set

- Supportive and preventive - Advance directive & living will



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