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PEDIATRICS - Physiological Integrity

Congenital Heart Defects

Cyanotic-right to left shunt
Acyanotic-left to right shunt

Ventricular Septal Defects-heart failure & murmur

Ss: scalp sweating & sudden weight gain
Surgical Repair: purse-string approach or
patch sewn over the opening
VSD – closes before 1 year of age

Coarctation of the Aorta

- Narrowing of the aorta
Ss: bounding pulses

Atrial Septal Defect- an opening bet the right & left atria
Left atrium over powers the right atrium
Ss: fatigue & dyspnea upon exertion
- surgery before age 5

Patent Ductus Arteriosus- like a traffic jam of blood

Ss: heart failure, machinery like murmur

Pulmonic and Aortic Stenosis

Pulmonic - pulmonic valve located in
the right ventricle
- asymptomatic,heart failure
- murmur & enlarge heart
Aortic- decrease CO2,murmur & heart failure
- opening in the left ventricle
Transposition of Great Vessels
- pulmonary artery leaves the left ventricle
& the aorta exits from the right ventricle.

Tetralogy of Fallot
- four defects that constitute
pulmonary stenosis,overriding aorta
right ventricular hypertrophy, vsd
Ss: skin bluish in color, heart murmur

Rheumatic Fever
- cause by beta hemolytic strep infection
ss: tachycardia,rash,fever,chest pain
migratory large joint pain,chorea &
skin nodules.
*administer penicillin until age 21

Kawasaki Disease
- vasculitis infection of the small vessels
ss: dry red cracked lips,rashes arms & legs
conjunctivitis,strawberry tongue,
peeling skin on the palms & soles of feet
high fever, unresponsive to antibiotic,
impaired swallowing,coronaryaneurysm
Gamma Globulin IV 400mg/kg/day x weight in kg
Live attenuated vaccine must delayed-polio,MMR

Ss: chest tightness & dyspnea,distant breath
sounds,wheezing episodes,fatigue & wet

Cystic Fibrosis
is hereditary disorder, lung congestion &
Ss: positive sweat test, bulky greasy stools,
meconium ileus,early chronic dry cough
deficient in vits. A,D &K fat soluble vits.

Down Syndrome
Ss: almond shape eyes,short broad neck
protruding tongue,low set ears,broad hands
w/ simian crease

Ss: frequent or persistent cough,heart burn
abdominal pain,recurrent aspiration,anemia
Main concern: airway obstruction,fluid and
Electrolyte imbalance & apnea

Pyloric Stenosis
Ss: mild vomiting turned into vomiting that
shot across the room,palpable mass RUQ,
Hirschprung’s Disease
-part of bowel there is no nerve cells,
no peristalsis in the section of the bowel
ss: constipation,foul smelling ribbon like stool
abdominal distention
- diagnosis established until infant is 6-12
months old
- 10x more common in girls than boys
- chronic seizure disorder asso. w/
recurrent unprovoked seizures.
Spina Bifida
- a congenital malformation of spinal column
- many areas of the central nervous system may
not develop or function adequately.
Ss: club feet,hip dysplexia,latex allergy or sensitivity

- affects female 10-13 yrs. Old
- brace must be worn 16-23 hrs a day,7 days a
week from 6 mos to 2 yrs to correct
- after surgery flat position, log rolling

ss: assymetrical hemline,unequal leg lengths,

morethan 5 degree deviation on scoliometer

Cerebral Palsy
- abnormal muscle tone & coordination,spastic
movement in one or more extremity, and
disturbances in gait & abnormal posture.

*ORTALENIS- click hip dysplasia,head of

femur displaced from
acetabulum,unequal leg lenght

ss: fluid volume deficit, altered nutrition,ineffective


Reye’s Syndrome
- mild viral infection, ICP Encepalopathy
Varicella chicken pox risk to develop Reye’s

Ss: viral URTI,severe vomiting,liver dysfunction, fever,

cerebral edema & increased ICP,irritability,
* Avoid aspirin administration w/ viral infection
- bronchioles become inflammed
- cause by a Respiratory Syncytial Virus RSV-
RSV- high affinity for respiratory tract mucosa
- prevalence in winter & spring

*Ribavirin – antiviral used to treat bronchiolitis

Caused by RSV
VIR meds means antiviral

Ss: wheezing in auscultation

- nephrosis of bowel tissue
- commonly occurs in male 3 & 5 yrs. old
Ss: vomiting,lethargy,sudden acute abdominal pain,
sausage shape abdominal mass,bloody stool
or jelly stool

Celiac Disease
- poor food absorption esp. gliadin
- patient unable to digest gliadin a by product of
*Serum anti-gliadin antibody- diagnostic test for
Celiac disease
*Gluten Sensitive Eneteropathy- other name

Ss: vomiting,diarrhea pale & watery,abdominal

distention,foul smelling stool

Diet: No B.R.O.W, iron supplements,vits ADEK

in water soluble

Cleft Lip and Palate

- cleft lip repair at 2 months
- cleft palate repair at 2 years
Sickle Cell Disease
- cell halfmoon shape, blood O2 decrease
- common to African-Americans
- cause of anemia- an imbalance bet. Red cell
destruction & production
- 12 to 20 days RBC life span
- avoid overheating during physical activities

Ss: hypoxia, organ dysfunction due to ischemia and

infarction,painful episodes

Esophageal Atresia & Tracheoesophageal Fistula

- infants do not have meconium because saliva
cannot enter the stomach

ss: 3 C’s – coughing, choking & cyanosis

- inflammation of tonsils, hinders swallowing
and breathing

ss: sorethroat,bad breath,mouth breathers snores

acute – fever chronic – apneic


Ss: sit upright position lean forward,chin thrust out

tongue protruding
*Haemophilus Influenza-B Hib- prevention for epiglo-


Ss: swelling,intense pain shortening of extremities
and limited mobility

Cast Care
Skeletal traction- buck’s traction,russel
Steinman pin,crutchfield
Halo vest,Gardner-wells tongs

Skin traction

Total Joint Replacement


Ss: presents w/ Heberden nodes or

Bouchard’s nodes
experiences loss of ROM,occurs in weight
bearing joints
- ESR,CBC,C-reactive protein det. Accurate
- Corticosteroids is not prescribed

Rheumatoid Arthritis
- auto immune disease,membrane around
joints inflamed,smaller joints
- cause by virus/bacterial infection
- ESR & CBC,C-reactive protein and
Rheumatoid factor,ANA & Antibody test
- DMARDS-Disease Modifying Anti Rheu-
Matic Drugs-infliximab (Remicade)
Etanercept (Enbrel),methotrexate

Ss: weight loss, morning stiffness,blateral swollen &

tender joints
Systemic Lupus Erythematosus
- auto immune disease that attack diff.
organs of the body
- lab. to det. high levels of antinuclear anti
body & Coomb’s test,high level of
C-reactive protein
- stress,sunlight exposure,infection can
contribute to lupus
- NSAIDS,corticosteroids,reduce stress
get plenty of rest & exercise are the

ss: exacerbation & remissions,mild to extreme fatigue

sudden unexplained weight loss, pericarditis,
nervous system/mental health problems,hairloss
Raynaud’s phenomenon

kinds of Lupus - Discoid Lupus- butterfly rash skin

Chemically /drug- induced lupus-hydralazine
Neonatal lupus- newborn

- acid crystal build in joints
- “TOPI” accumulation of crystals big toe
- Over production of uric acid,reduce ability
of kidney to get rid of uric acid
- Diabetes, obesity & sickle cell anemia
increase the risk
- May cause join deformity & limited
- Synovial fluis analysis,joint x-rays, uric
Acid elevated Men-6mg/dl women 5mg/dl
- diet low in purines,NSAIDS, cortico-
steroids, clochicine, indomethacin

Ss: pain is throbbing, crushing, excruciating,warmth,

tenderness & redness of joints
- elevate on pillow for first 24 hours
- prevent hip/knee contractures
- limb sock must be worn under the pros-
Crutch Walking
- bear your weight to hands not in armpit
- position crutches 4 inches to side &
4 inches to front
- Swing-through-gait, three-point-gait,
Swing-to-gait are the 3 types of technique
- Tripod gait is used when client unable to

Common drugs for Orthopedics

Anti-resorptive agents – ex: Calcitonin
Biophosphonates - ex: Fosamax
Bone forming agents - ex: Flouritab, androgens
NSAIDS - ex: Celebrex, Mobic
Antineoplastic agents - ex: Methotrexate


Physiological Adaptation
Psychosocial Adaptation
Signs of Pregnancy
Family Planning


hCG – biological marker of pregnancy

Alpha Fetoprotein- present when the baby amnio-
centesis neural tubal defect

Maternal Hypertension – most common cause of

fetal growth retardation
Ectopic Pregnancy
- zygote implants outside the cavity
- Intra abdominal bleeding is common
cause of ectopic pregnancy.

Ss: sharp localized pain when the cervix is touched

during vaginal exam, sudden acute abdominal
pain , Keh’r sign – pts. lie down there is a pain
in the tip of shoulder
due to accumulation of fluid in the peritoneal
cavity,due to rupture of zygote

Methotrexate (Trexall) – treatment a folic acid anta-

gonist, inhibits cell growth, allowing the tube to
be saved
Laparoscopy – small incision into the tube & removal
of embryo

Hyperemesis Gravidarum
- increased BUN & decrease urinary output
- ketoacidosis-breakdown of fat stored to
make metabolic needs.
- high level of hCG & estrogen

Hydatidiform Mole
- absence of FHTs, grape-like clusters
of vesicles, vaginal discharge that may
contain vesicles,uterus enlarge to fast.
- Asian women at risk 45 yrs and above.
- hcg should be measured weekly until
normal then rechecked every 2-4 weeks
then every 1 to 2 months for 6 months
to 1 year
Interventions: surgical removal of neoplasm,monitor
ring for pre-eclampsia & choriocar-
cinoma , hysterectomy
Incompetent Cervix
- cervix dilates prematurely usually occur
during 4 mothns of pregnancy
- repeated spontaneous & painless second
trimester pregnancy.

Ss: suddenweight gain,swollen hands and feet,
Headache, and blurred vision, hypertension
Severe if diastolic more than 110, Mild 140/90
Weight 2 kilos/week
Magnesium sulfate is the drug of choice and
should be monitored for toxicity done
every 1-2 hrs.
- diminishes neuromuscular transmission,
promotes maternal vasodilation and has
anticonvulsant effect.
Diminished deep tendon reflexes sign of
Magnesium sulfate toxicity.

Placenta Previa

- painless vaginal bleeding, low

implantation of placenta

Placenta Abruptio
- sharp sudden abdominal pain
- premature placental separation\
- causes, cocaine use, PIH, manual vacuu
aspiration, abortion procedure,rapid
decompression of the uterus multipara
domestic violence
Premature Labor
- can sometimes be stopped by hydrating
the mother and by treating vaginal & UTI
- Bethamethasone,celestone IM injection
to help maturation of the lungs
Labor & Delivery
Prolapsed Umbilical Cord
- knee-chest position
- c-section immediately
- cover umbilical cord with saline bandage
Post Partum

- hydrop’s fetalis a serious hemolytic

reaction baby experience severe anemia
cardiac decompensation,edema
- Rhogam can give to mother w/ Rh+ baby,
After spontaneous or induced abortion,
Amniocentesis or chronic villi sampling,
Bet 28 & 32 weeks of gestation,RH- with
Bleeding episodes.
- Serum bilirubin normal values .2 to .6
- Golden-colored amniotic fluid is severe
Fetal disease asso. w/ Rh factor
- Direct Coomb’s test is done w/ the
to measure the number of antibodies in
her blood
Indirect Coomb’s test is done on baby it
tells if there are any antibodies stuck to
the red blood cells.

Newborn Care
- Ballard scale, a newborn assessment
maturating scale
- Respiratory Rate 30 to 60 breaths/min
with 10 seconds apnea
- Red reflex test serious visual defects is
performed in small dark room looking at
the retina there’s a red reflex equally red
to roll-out any defects of cornea.

CARDIAC Physiological Integrity

Cardiac Rhythms
Conduction System
ECG Complex
ECG Grid

Lead Placement
Snow over grass- right side
Smoke over fire - left side

Interpreting Rhythm Strips

Normal ECG
Normal Sinus Rhythm
Sinus Bradycardia
Sinus Tachycardia
Supraventricular Tachycardia SVT
Atrial Fibrillation
Atrial Flutter
Premature Ventricular Contractions PVC’s
Venticular Tachycardia
Ventricular Fibrillation
First Degree Block
Type 1 Second Degree AV Block
Mobitz 1, Wenckebach
Type 2 Second Degree AV Block
Mobitz 2
Third Degree AV Block
Complete hear block

Congestive Heart Failure

Left sided Heart Failure

Ss: blood tinged frothy sputum

dyspnea, cough, crackles pulmonary
congestion, irritability, anxiety

Right sided Heart Failure

Ss: peripheral edema

ascites, nocturia, hepatomegally

Monitoring/testing: BNP & hemodynamic monitoring

- Cardiac marker for CHF
Echocardiogram & Chest X-ray
Allen’s test

Myocardial Infarction
Ss: shortness of breath, crushing pain that radiates
to his neck and left arm
decrease CO2, increase WBC, increase temp.
ST segment depression, T wave inversion,Q

CPK MB, LDH, Troponin q8 hrs
Coronary arteriogram & 12 lead EKG
MUGA Scan-used to measure heart function by
determining the ejection fraction, this is the
percentage of blood ejected from the heart w/
each beat

MONA- Morphine-Oxygen-Nitroglycerine-ASA
Fibrinolytics- are used to dissolved clots &
reduced the size of infarction
- must administered 6 hrs post MI
- before administered insert 2-3 large bore
peripheral IV’s
- monitor for bleeding, neuro vital signs
watch rhythm
PTCA- procedures performed on a double
vessel disease.

Anti-embolism stocking- to prevent venous stasis

and thrombophlebitis.

Repolarization- ventricles are resting & then

fill up with blood

Dressleis Syndrome- combination of pericarditis

pericardial effusion & constrictive peri-
carditis. Immune symptoms reaction

Angina Pectoris
Ss: dull chest pain

Treatment: Beta-blockers & calcium channel

Blockers ends with pine

Ex: Procardia (Nifidipine)

Norvasc (Amlodipine)
Cardiac Tamponade
Ss: tachycardia & distended neck veins
Pallor, cardiac rhythm changes

Treatment: elevate head of bed 60 degrees

Vessel Insufficiency

Chronic arterial Insufficiency

Chronic venous insufficiency
Deep Vein Thrombosis DVT

SS: tenderness and warm to touch, increase

pain with ambulation,no pulse to the affected
extremity, dull ache in calf, one side swelling,
heavy sensation
Causes of DVT: CHF,MI,obesity,fractures,sepsis
Hematological disorder,pregnancy,malignancies,

Treatment: Doppler of the lower extremities,

Venography- due to any clog artery

Buerger’s Disease
SS: numbness & tingling sensation of the toes
pale finger tips, weak peripheral pulses,ischemic
ulcerations, intermittent claudication

Tx & Mngmt: smoking cessation, promotion of

Isometric exercises.

Raynaud’s Phenomenon
SS: hand & fingers turning white
Causes: smoking & stress
Precautions: over the counter cold remedies such
As Sudafed,clonidine,migraine, meds
Contain ergot alkaloids
Ss: fever, clubbing of fingers, malaise, cardiac
murmurs, anorexia

Types of Shock
1. Hypovolemic- volume reduction ex: bleeding, burns
2. Cardiogenic – unable to circulate ex: dysrythmias,
3. Neurogenic – loss of vasomotor tone ex: spinal cord
Injury, spinal anesthesia
4. Septic –dilation of blood vessels ex:gram negative
5. Anaphylactic- antigen-antibody reaction ex: transfusion
Reaction,allergies, insect bites.

RESPIRATORY Physiological Adaptation

- removal of fluid from pleural space 50cc
Procedure: take chest x-ray & vital signs
position the client sitting up over bedside
table or lying on unaffected side with
HOB at 45 degree
tell client not to cough,breathe deeply or
move during the procedure

Chest Tubes
- reestablish a negative pressure
- done when there is a fluid build-up in lung
- lung cllapse
- spontaneous collapse
- Fluctuation will occur when the suction is
working properly
- bubbling becomes continous,vigorous or
excessive it means there is an air leak in
the system
- inserted at 2nd ICS at the midclavicular

Tension Hemothorax- complete collapse of the lung

- an be fatal as the accumulating
pressure compresses vessels
decrease venous return and decrease
cardiac output
Hemothorax – is a collection of blood in the pleural cavity
Pneumothorax – is a collection of air/gas in the pleural

Fracture of Sternum/Ribs
Flail Chest – tachycardia,assymetrical, multiple fracture

End expiration – the vent exerts a pressure into the lungs to

to keep alveoli open

Ventilator – improves gas exchange and decreases work

of breathing

PEEP Positive in Expiratory Pressure – expands the thorax

and realign the ribs, denotes amount of
in the end of expiratory pressure.

BIPAP Bi level Positive airway Pressure - is used often with

pulmonary edema but may be done prior to
CIPAP Continuous Positive Airway Pressure

Lung sounds - nursing assessment for


Pulmonary Embolism
Ss: shortness of breath, cough & increase heartrate,
Hypoxemia, chest pain,hemoptysis, angina

- it can occur when a clients become

- clients who have venous stasis
- women who take birth control pills

D-dimer – a lab. work detects presence of high fibrin

clot, thrombus
VQ Scan – ventilation perfusion scan, inject isotope
to measure

TX: oxygen, heparin or Coumadin warfarin,

Surgically placed filter in vena cava.

Chronic Obstructive Airway Disease

Ss: cough & sputum production

Lab/Test: chest x-ray, chest CT, pulmonary function

Tests, ABG

Blue- patients suffering from chronic bronchitis

Pink – patients suffering from emphysema

Tx: bronchodilators,theophylline,inhaled/intravenous/
oral steroids, & antibiotic.
- it destroys alveoli
- it narrows & collapses small airways
- it causes the lungs to lose elasticity

Tx: high in carbohydrates, increase fluid intake

As alveolar wall dies, there is less surface for gas


Types of asthma:
1. Emotional – cause by person
2. Extrinsic – caused by dust,mold,pets
3. Intrinsic – common cold, allergens
4. Mediated


Endotracheal Tube
Goal: to position the end of ETT 2 cm above the
-tion of the lungs or the carina

Special Double Lumen ETT – have been developed for lung

-and other intrathoracic surgery
-this tubes allow one lung ventilation while the
-other lung can be collapsed to make surgery
-ETT with a suction port are proven to decrease
- the amount of bacteria which could possibly
-grow in the secretions

Acute Respiratory Distress Syndrome

-alveolar spaces are filled with fluid
-prone position, it makes more alveoli accessible
-ABG indicators if ARDS is improving.

NEUROLOGY – Physiological Integrity

Neurological Assessment
Frontal Lobe- damage, changes in behavior

Neurological assessment:
Mental Status- most important indicator
Pupillary changes- 2-6mm normal pupil
Motor strength & coordination
Corneal assessment
Vital Signs- widening pulse pressure when there is
Increase ICP
Movement- is the lowest move, speech is the highest
level of brain neuro function

Noxious Stimuli Reaction- the client will pull away from

Stimuli used:
sternal rub,supraorbital pressure,nailbed
pressure, trapezius squeeze

Oculocephalic Reflex test (doll’s eye reflex) &

Oculovestibular Reflex test (Ice waterCaloric test)–
performed assessing Brain Stem Function

Babinski Reflex – stroked on the lateral part of foot of an

under 1 year old + is ok, - is bad
over 1 year old + is bad, - is ok
Negative- curled down
Positive – curled up

Reflex table – 0 = absent

1+ = present,diminished
2+ = normal
3+ = increase but not necessarily
4+ = hyperactive

Computed Tomography CT Scan

- identify certain lesions
- takes pictures in slices
- he will need to take his head still
- consent due to the dye

Magnetic Resonance Imaging MRI

- identifies abnormalities in soft tissue
- using a magnet last to 1hour
- client must void prior to exam
- clients w/ claustrophobia cannot receive
this exam
- clients can talk & hear during the scan
- client will hear a thumping sound

Cerebral Angiography
- catheter inserted w/ a dye to the brain
- consent due to the dye
- metallic taste in mouth
- warm sensation during the procedure
- clients well hydrated during the
- risk of embolus
- check for pulse, hematoma & change in
- 12-24 hours of bed rest

- is an x-ray of spinal & sub arachnoid
- air & water base
- NPO 8-12 hours
- Does not require a heavy sedative
- Dye is injected to sub arachnoid space
- Trendelenburg position for Air
- 30 to 50 degrees for water
- Must be flat in 6-8 hrs.

After procedure observe for the Signs:

Stiff neck & chills

Brudzinski’s sign- when neck is flexed your knee & hips is
also flexed.
Kernig’s sign- flex the knee the opposite leg cannot extend
Photophobia & headache

Electroencephalogram EEG
- diagnose seizure disorder
- records the electrical activity of the brain
- helps in screening for a coma
- 3 flat EEG reading indicate brain death

Nursing care:

- put patient in dim light & quiet room

- no caffeine alter the results
- no sedatives 2-3days prior alter the result
hold sedatives

- medicated w/ a mild sedative
- may have not caffeine
- eat a light breakfast
- we may flashlights in the face

Lumbar Puncture
- performed when patient is on
unexplained fever and elevated WBC
- invasive procedure
- punctured site is 3rd & 4th lumbar sub-
arachnoid space
- knee chest position, fetal position lie on
right side
- 4-8 hours flat on bed to prevent spinal
Headache, post procedure
- Fluid &blood patch- pull out blood use it &
inject at pain area
- Normal CSF- clear, no RBC
- Abnormal CSF- cloudy, increase protein,
Performed when: check for blood, measure pressures,admi-
-nister drugs intrathecally.

Brain Herniation
- cause a sudden decrease of ICP
- the brain tissue is pulled down through
foramen magnum

Epidural Hematoma
- arterial bleed
- gain & lost of consciousness for minutes
- pts. See stars
Tx: burr holes,remove the clot and control ICP

Subdural Hematoma
- venous bleed

Acute & fast – s/s bet. 24 to 72 hours after slow bleed, non-
acute bleed
Tx: remove clot to control ICP
Sub-acute - s/s bet 72 to 2 weeks w/ rapid
Scalp Laceration- infections is the problem

Skull Injury
- may or may not damage the brain

ss: Battle sign-bleeding over the mastoid

Racoon eyes-peiorbital bruising
Cerebrospinal rhinorrhea

Basal skull fracture- bleeding from eyes, ears, nose, throat

fracture at the base of the skull

Open fracture – dura is torn

Depressed fracture – is usually require surgery

Ss: headache, dizziness, seeing spots
diff. waking up or speaking, confusion, severe
headache & vomitting
- the brain is bruised w/ a possible surface
- progressive disease, irreversible, loss of cerebral
function due to cornical atrophy
- begins 40 to 65 y.o. , 8 to 10 years onset to death

Early stage- memory loss, subtles personality,diff of

Middle stage- language is impaired, difficulty w/ motor
Final Stage- complete loss of language
Rohin’s stage- loss of bowel & bladder control

Ss: progressive decline in recent & remote, aphasia,

agnosia cannot recognized memory, cannot learn
new things, recall, recognized information

Nsg. Management: promote clients independence

Promote contact with reality
Establish a routine

J- impaired judgement, inappropriate

O- orientation confused
C- confabulation, inventing stories, defense mechanism
A- affect
M- mentally impaired

Parkinson’s Disease
- decreased production of dopamine

ss: mask-like facial expression, fatigue, stiffness,

rigidity & diff. rising from sitting position
TRAP- tremors,rigidity,akinesia,poor balance

Lab/test: EEG,MRI,CT Scan

Tx: levodopa, anticholinergics (akineton),
-lessened rigidity & tremor

- excision of vertebral arc, herniated disc
- nurse must assess for circulation &
motor sensory checks, dressing, bowel
& bladder function
Cervical Laminectomy- level of consciousness
Lumbar laminectomy- circulation, motor, 5 p’s, pulse,pallor

Amyoptrophic Lateral Sclerosis LOU GEHRIG’S

- the brain is fine but the body deteriorates
- is a degeneration of upper & lower

ss: mildly clumsy, weakness of upper & lower extremities

atrophy of the muscle & extremities, trunk

Tx: muscle relaxants for spasticity, speech theraphy

Multiple Sclerosis
- 3rd leading causes of death in the US
- Destruction of myelin sheath of the brain
- Demyelination of white matter
the brain and spinal cord

Motor- weakness, paralysis,spasticity, gait disturbances

Cranial nerve – blurred vision,dysphagia, diplopia, facial
Cerebellar – dysarthria, tremor, incoordination, ataxia,
Sensory – paresthesias,decrease proprioception
Cognitive – decrease ST memory, difficulty w/ new
word finding difficulty, short attention span
Tx: lumbar puncture, MRI, evoked potentials or
ACTH Adrenocorticotrophic hormone, physical the
raphy , occupational theraphy, encourage exerci

Glasgow Coma Scale

- measures level of consciousness
- involves 3 responses, eye opening, verbal
response, best motor response

Coma – is defined as, not opening eyes, not obeying

commands, not uttering un
derstandable words

Coma clients is 90% less than or equal 8

8 is the critical score

8 at 6 hours, 50% die
> 9 not in coma
9-11 moderate severity
> 12 is a minor injury

Cerebrovascular Accident Stroke

Risk Factor: uncontrolled hypertension
Smoking & obesity
Increased blood cholesterol
Chronic atrial fibrillation
African-american males over 65 y.o.

Transient ischemic attack- double vision, left side of

the body paralyzed

2 types of stroke:
Hemorrhagic stroke – blood vessel rupture with bleeding
into the brain, hypertensive & older patients

Ischemic stroke – slower onset, caused by cerebral


Subarachnoid hemorrhage- cause by a rupture of

Cranial aneurysm
Epidural bleed- artery is involved
Subdural bleed – vein I sinvolved

Guillain Barre Syndrome

- last for 6 months
- need mechanical ventilation
- require intubation
- recovery period for few weeks or few

Ss: rubbery legs, weakness progressive upward over a

period of two days, arms & facial muscles have been

Myasthenia Gravis
- problem in neurotransmitter, myelin
sheath is intact, but decrease
acetylcholine production

ss: drooping of eyelid, speech and swallowing disorder,

blurred vision, sensation remained intact

Head Injury
Intracranial Pressure ICP
Spinal Cord Injury
PSYCHIATRY – Psychosocial Integrity

Post Traumatic Stress Disorder
Panic Disorder
Personality Disorder
Obssesive-Compulsive Disorder
Dissociative Disorders
Electro-Convulsive Therapy ECT


Hyperthyroid Graves Disease

Hypothyroid Myxedema
Parathyroid Problems
Cushing’s Disease

Lung Cancer
Laryngeal Cancer
Bladder Cancer
Stomach Cancer
Cervical Cancer
Uterine Cancer
Breast cancer
Colorectal cancer
Prostate cancer
Branchytherapy Internal Radiation
Teletheraphy & Beam Radiation External Radiati

GASTROINTESTINAL – Physiological Adaptation

Ss: severe abdominal pain RUQ, rigid
around umbilical or flank area, ascitis, abdominal
-worsen after eating & lying flat
-decrease hemoglobin & hematocrit
-alcohol consumption is the number one cause
-no morphine can cause spasm of odi spinchter
-give calcium supplements

Fecal occult blood- blue litmus paper signs of bleeding

Medicines: Zantac – decrease acid productions,H2

Antacids – counteracts stomach acidity
Protonix – decrease gastric acids,privacid
Carafate- barriers of acid
-liver cells necrotic, destroyed & replaced by scar
-increase ammonia level, fiteb breath, bleeding
-risk for esophageal varices & portal hypertension
-increase bilirubin in urine & increase SGOT & SGPT
-decrease serum albumin & cholesterol
-impaired aldosterone metabolism results to edema
-providing thiamine & B12
-bleeding precautions, avoid Im injections & aspirin
-measure abdominal girth
-do not give narcotics
-diet must be low in protein & sodium

LV Shunt- remove fluids in peritoneal cavity

Ss: abdominal pain, jaundice, anemia, ascitis, clay

colored stool, splenomegally, chronic dyspepsia,
firm & nodular liver

-small inflamed protruding sacs in the colon that have
-causes impacted stools, history of constipation,
Low fiber & high carbohydrates

ss: left lower quadrant pain,chills,fever,nausea and


Hepatic Coma
-is diagnosed by examining the serum ammonia level
-prescribed lactulose (Cephulac) & Neomycin SO4
-decrease protein in the diet,monitor serum ammonia
-recommend cleansing enema

Ss: confusion & delusion,motor changes,difficult to

Awake,asterixis flapping tremor,fetor hepaticus
Musty odor, increase ammonia level

Bleeding Esophageal Varices

-liver is damage and that collateral circulation has
formed into 2 of 3 places are rectum,stomach
& esophagus
-portal hypertension, increase blood in the liver
-coughing & straining can cause rupture of the
-Sandostatin-works to lower the BP in the liver
-Sengstaken Blakemore tube in the bed side
-administer oxygen

Ss: black tarry stools,paleness,lightheadedness

Ulcerative Colitis
-inflammation of ascending colon & rectum
-condition affecting the large intestine
-low fiber diet to limit motility
-avoid meals that are cold
-steroids to decrease the inflammation

Ss: rectal bleeding,diarrhea,bloody or mucosy stool

fever & loss of appetite,constipation,weight loss
anemia,rebound tenderness

test: colonoscopy,barium enema,sigmoidoscopy


Schilling Test- to test Vit. B 12 in urine

Koch’s pouch- ileostomy, there is internal reservoir

(stoma & bag)
Colostomy- permanent stoma is red/pink
- irrigate sametime everyday after meal
Ileostomy - temporary don’t irrigate as much
- no raw vegestables,nuts,grains & peas

Chron’s Disease
-iflammation or ulceration of digestive tract,chronic &
ss: blood in stool,rebound tenderness,cramping &
dehydration,anemia,diarrhea w/ steatorrhea,
cramping after meals,abdominal pain,vomiting
& fever

Partial Bowel Resection – to allow the intestine to rest

and heal
Transvers- semi-soft stool
Descending – formed stool
Ascending – liquid stool

-associated w/ diet low in fiber
-elevate head of bed after any abdominal surgery

Ss: increased WBC,sharp pain on right side,nausea &

Vomiting,rebound tenderness
-pain that is worsenes w/ food
-pain & burning worsend at night & lying down
-mainly found in males
-can be found in the stomach,esophagus,duodenum
-avoid spicy foods & caffeine,stop smoking
-avoid extreme temp hot or cold

Gastric ulcer-pain 30 mis. to 1 hour after eating meal

when vomit the pain subsides.

Duodenal ulcers- pain 2 to 3 hrs. after eating

as long there is food in stomach
theres no pain

Gastrectomy- give vit B12 for life

Billroth I – portion of stomach connect to duodenum
Billroth II – large potion of stomach connect to

-board like abdomen,low urine output,,nausea &
Dumping Syndrome
-increase circulation of stomach
-give complex carbohydrate,avoid simple
carbohydrates, high fiber
-is more common in Billroth II
-recumbent position, drink bet meals
-lie left side after meals,eat high fat & protein
-decrease stress

Ss: cramping,diarrhea,weakness

Hiatal Hernia
-the hole in the diaphragm is too large,the stomach
moves up into the thoracic cavity
-small protrusion close to the navel
-causes, congenital abnormality,trauma,surgery
-small frequent meals,elevate head of bed,take small
bites,avoid spicy foods

Ss: abdominal mass soft can be palpate w/ out pain,

fullness after eating & regurgitation

Hyperalimentation TPN
-need to change the tubing with each bag every 24
-can be hung for 24 hours
-taper off TPN when discontinuing
-needs to be check by 2 nurses before each bag is
-put in pump
-other medications cannot be infused, only insulin,
Lipids, K+
-can be mixed daily
-IV bag should never be covered
-infection can be frequent complication

Laboratory values to be monitored:

Blood glucose,ketones,BMP,magnesium
Dobhoff Tube
-a small bore NG feeding tube not attached to suction
-more comfortable & less complications
-can remain place for weeks

Central Line
-have client in trendelenburg
-rolled towel to middle of back
-air from getting in the line,clamp it off
-cap the end of tubing,cover the end w/ syringe
-position the patient on the left side in case air
will get into the line
-post insertion chest xray performed to ensure
proper placement
-10ml syringe use in central line

Diagnostic Tests

Barium Enema
-drink clear liquids
-take laxatives or enemas until clear
-ensure post procedure bowel movement

Liver Biopsy
-PT/INR,PTT prior to procedure
-position pt supine w/ hand behind head
-have client lie on affected side for 8 hours
post procedure

-have pt. sit in high fowlers position
-have pt. empty his bladder prior to procedure
-the fluid removed will be yellow
-monitored for signs of shock

GENITOURINARY – Physiological Adaptation

Benign Prostatic Hyperplasia

-frequent waking at night to urinate
-serum PSA & urinalysis
-PSA secreted by pituitary gland
Prazosin (minipress) – helps the urination urgency
Doxazosin (Cardura) – helps the symptoms of BPH

Prostatectomy- normal to pass urine in blood tinged &

blood clots & tissue debris

Percutaneous Renal Biopsy

-instruct the pt to restrict food & fluids for 8 hrs
before the test
-administer mild sedatives 30 to 1 hour before
-check vital & inform pt. to void before procedure
-place pt in prone position
-observe for bleeding & hypotension

Nephrotic Syndrome
-leaking of the protein into the urine
-perform U/A,glucose tolerance,serum protein,
Serum albumin,renal biopsy
-edema,swelling around eyes,extremities &
-circulating blood volume decrease causing kidney to
activate its Renin Angiotensin cascade,aldosterone
is produce to retain sodium & H2O
-Corticosteroids,prednisone & Diuretics drug of choice

Acute Glomerulonephritis
-sorethroat,headache & lower back pain
-protein in the urine,increase BUN & creatinine,
hematuria & hypertension
-strep infection is the main cause
-common bet age 6 to 7 yrs. old
-antibiotics,bedrest & increase carbohydrates in diet
-decrease protein & sodium in the diet and dialysis
-reddish brown urine

Renal Failure
-sudden loss of kidney function resulting in electrolyte
imbalance 7 retention of nitrogenous substance
-during oliguric phase the patient is in a fluid volume
-diet should be in high carbohydrates
-low protein,sodium,potassium & phosphorous

Urinary Tract Infection

-fluids morethan 3,000 ml, acid ash diet
-avoid coffee & tea
-Medicines: Ofloxacin (Floxin)
Nitrofurantoin (Macrodantin), Pyridium
Cotrimoxazole (Bactrim)

-access route are: External AV shunt,fistula,femoral/
Subclavian cannulation
-fistula access 3 months to mature
-must be done 3-4 times a week
-during treatment period monitor for: depression,
suicidal tendencies,electrolytes & BP
-bruit & thrill must be assessed before accessing
hemodialysis access ports
-cathflo must be used if pt allergic to heparin
-decrease protein, sodium & potassium in the diet
-pt. w/ unstable cardiovascular system cant tolerate

Peritoneal Dialysis
-dialysate is warm to increase blood flow
-patients who get peritoneal dialysis cannot tolerate
-possible complications are: peritonitis,respi. Diff.
protein loss
-cloudy drainage,there is an infection, it should be
tinged color
-if the fluid does not come out, turn the pt side to side

Intravenous Pyelogram
-NPO 8 hrs before the test
-sitting straight up during procedure
-after procedure, increase fluids,apply warm soaks if
hematoma develops

-involves a lighted scope which is used to visualize the
-consent, anesthesia, a sedative and enema can be
-used to diagnosed & evaluate urinary tract disorder,
enlarged prostate,recurrent bladder infection
-notify doctor if there is still blood in the urine after
3 days
-expect burning on urination

-only pulls off water
-has the same principles applied as hemodialysis
-may be utilized w/ peritoneal dialysis or hemodialysis

Kidney Stones Renal Calculi

-increase fluid intake and modify his diet,avoid high
contain of calcium & oxalate
-strain his urine

Calcium Oxalate: beer,rhubarb and wheat germ,

Calcium Phosphate: milk & milk products, foods high
calcium, meats, grains &
Uric Acid: avoid Vit C supplements, corn & lentils

EXtracorporeal shock wave lithotripsy (ESWL)

Pelvic Inflammatory Disease

-history of menses,sexual habits, contraceptives
-look for signs of hypovolemia,hypotension &
-Medicines: Quinolones,cephalosporins & tetra-
-cyclines, penicillins

Continous Ambulatory Peritoneal Dialysis CAPD

-increase protein & fiber in the diet
-ambulatory walking around w/ peritoneal dialysis
going on
-complications: hernia, peritonitis, low back pain,

Continous Renal Replacement Therapy CRRT

-little bit longer than hemodialysis
-is less aggressive
-has only 80ml of blood in the machine at any

Hemoglobin: male 13-18

Hematocrit: 42-52%

Urine Specific gravity: 1.005-1.029