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(31 JANUARY – 17 FEBRUARY 2005, PICC, City of Manila)
DAY 1 (31 JANUARY 05) STEPS IN PASSING Have a Right Attitude THINK POSITIVELY … have a Fresh Start KNOW what YOU WANT and HOW TO GET IT OVERVIEW OF ESSENTIAL CONCEPT TRY OUT Focus assessment 7 habits of SUCCESSFUL EXAMINEE
MOSBY – growth and development LIPPINCOTT – care of the Elderly and Communicable Disease DIGOXIN – monitor the creatinine… “ the TV DOESN’T look good to me” (DIGOXIN TOXICITY – nausea/vomiting, abdl cramps) Olive = butter CK – normalize 1 – 3 days after MI LDH - 10 – 14 days ATRIAL FLUTTER – SAW TOOTH PROCESS OF ELIMINATION consider MASLOW’s H of NEEDS consider the COMPLICATION whether ACUTE CHRONIC ABCs SAFETY FIRST NSG PROCESS
– ALWAYS prioritize
MMR VACCINE – only vaccine for HIV pt. Pt on HEPARIN – APTT (N 30-40sec), therefore if INCREASE – bleeding POISON - nursing action in order : #1 CALL poison control center # 2 MINIMIZE EXPOSURE of pt to poison – pull him/her away from the poison # 3 IDENTIFY the poison
– s/e tinnitus, vertigo, ototoxicity, oliguria – for ELDERLY : N level NOT more than 1.0meq/L ADULT : N .5 – 1.2 meq/L
HEPA B diet : low fat, increase CHON
DOWN SYNDROME – large tongue – feeding problem – poor sucking (infants) SAFETY PRINCIPLE 1. when can a child USE ADULT SEAT BELT? - if the infant is 40 lbs and 40 inches in height seat belt location in car: BACK CENTER SEAT 2. TODDLER – falls 3. SUPRATENTORIAL craniotomy – semi fowler’s position INFRATENTORIAL – flat in bed 4. SCATTER RUGS – osteoporosis pts. 5. TRIAGE ; burns, open fx – “SHOCK” Things NOT TO BE DELEGATED by RN: Assessment, Teachings, Evaluation Pt 50y/o and - mammogram – once a year.
Pt with PKU – LOW PHENYLALAMINE DIET (NOT phenyl FREE). – therefore LOW CHON Pt with Rocky Mountain Fever – exposure to dog ticks Lyme’s Dses – deer ticks PSYCHE PATIENTS 1. remember to stick to unit rules/policy – be consistent to pt. 2. encourage verbalization – “tel me how…..” 3. sound knowledge of cultural diversity - seek help of interpreter 4. acknowledge pt feelings – “it seems….” “this must be difficult…..” 5. emphatize with your patients’s feelings “ I understand how you feel…..” CATARACT – CAUSES – aging and trauma MRSA (methicillin resistant staphyliccocus aureus) - USE GLOVES AND GOWN WHEN W/ PT
DAY 2 ( 01 February 05)
1. GROSHONG CATHETER HICKMAN BROVIAC - 2 lumen - 3 lumen - 1 lumen
ALL requires Central Venous Access - sites: cephalic, brachial, basilica and superior vena cava
For TPN Administration of Chemo Agents, Blood Products, Antibiotics
COMPLICATION:Thrombosis and Bleeding 2. CHEST TUBES – Water Sealed Drainage Types: Anterior – w/c drains AIR Posterior - w/c drains FLUIDS Water Sealed Drainage : 1 bottle, 2 bottle and Three bottle system 1 BOTTLE : 2 BOTTLE : 3 bottle : 3 – 5cm of only (length of tube to be emerge) First bottle – drainage bottle (no tube emerge), 2nd bottle - long rod 3-5cm FREQUENTLY USED 1st bottle – drainage 2nd bottle – water sealed 3rd bottle – suction bottle control COMPLICATIONS: Nsg ALERT: NORMAL : BUBBLING is N in the 3rd bottle – it indicates that suction is ADEQUATE (if no bubbling STOPS in the 3rd bottle, meaning – inadequate suction) ABNORMAL : if bubbling occurs at the 2nd bottle – indicates LEAKAGE – action, check sealed at air tight container and the pt and bottle connection. bubbling, breakage, blockage
In case there BREAKAGE, have extra bottle and emerge tube ASAP to prevent entry of air and or may use forcep to clamp tube temporarily. If pt. ambulates, keep bottle LOWER than the patient. ABSENCE of OSCILLATION at the 2nd Bottle – indicates blockage
TOWARDS THE BOTTLE - When MILKING the tubings. EMERGENCY EQUIPMETS AT BEDSIDE: xtra bottle,clamp, gauze
3. TRACHEOSTOMY TUBE - to maintain patent airway for pt w/ neurological problems and musculoskeletal disorders.
STOP . NASO GASTRIC TUBE – stomach and intestine (duodenum) Types: Levine Tube – for stomach .if pt (infant) is having enteric coated meds. tip of nose to earlobe to XP + 7-10 inches for intestinal NGT 3. tip of nose to earlobe to xyphoid process (for stomach) 2. AVOID: water sports – swimming 3. insert obturator to keep it open 2. . I for lavage/gavage) . problem: spasms that lead to arrhythmia C-STENT (cardiac-stent) – alternative to PTCA Maintains patency of bld vessels Problem: dislodge IABP (Intra Aortic Balloon Pump) . Ribbon or ties @ side of the neck only to avoid pressure. request for change in form of meds Miller Abbot – for intestinal (w/ mercury b4 injection) . infection and arrhythmia 5. 4.nursing care: 1. PENROSE DRAIN .1 lumen. In changing ties – insert new one first BEFORE REMOVING old tie. 5.remove gradually 6.if accidentally dislodge. 4.for Cardiogenic Shock problem: thrombus formation.2 lumen (I for suctioning. Suctioning – 10-15seconds .1 lumen Nursing Care for NGT: 1.if (+) bradycardia. PTCA – enlarge the passageway for bloodflow. for lavage (cleaning) and gavage (feeding) Salem Sump – for stomach .2 lumen (insert then inject the mercury) Cantor – for intestinal .wound drainage system . Before and After suctioning – hyperoxygenate the patient. accurate means to verify correct placement: ALWAYS consider Two checking criteria: ASPIRATION and Gurgling Sounds .doctors the one who removes this.
9.Report the following: If (-) or decrease drainage.place drainage bag at the level of t-tube (obstruction of t-tube – there will be excess drainage) 500 ml – N drainage in 24hrs. WHEN TO EMPTY: when its usually 1/3 to ½ full then RECORD the amount. n/v . abdl cramps. Before feeding check for placement. (+) nausea and vomiting (+) abdml rigidity Characteristic of Gastric Residual: more than 50 mo and coffee ground. 7.nsg care : report s/s of infection.to drain excess bile until hearing occurs . T TUBE .for pt (+) lesion at esophagus . THREE-WAY FOLEY absence of clot – effective Characteristic of drainage – 2-3 days after surgery (bloody to pinkish) – NO NEED TO REPORT THIS – it is expected . if report ASAP. 10. HEMOVAC JACKSON-PRATTS (JP) BOTH used as close wound drainage suction system BOTH system function on the system of (-) pressure.provide adequate skin care PEG – incision at skin .long term therapy 8. JP – compress the container before attaching to the drainage. GASTROSTOMY TUBE (GT) PEG • both for NUTRITIONAL PURPOSES GT – incision (abdomen to stomach) .
inserted directly at the bladder wall .cereals. for meds) . . SENGSTAKEN BLAKEMORE TUBE . addtl calories (300 cal/day) average of 2400 .3 lumen ( for esophageal balloon. CALCIUM : RDA is 1000 then +200mg/day (broccoli. URETHRAL CATHETER – to drain urine.check if properly anchored 12.2700 b.cheese) e. Galactogogues – increase production of milk PEDIATRIC pt – by 4-6 mos – START iron supplement due to iron depletion and (-) extrusion reflex. dietary preferences Instruct pt on what to avoid For pregnant pt. Persistent bubbling at water drainage bottle – for bottle #2 – check if tubing is properly sealed. . note dietary changes: a.tuna. vegetables.11. SUPRAPUBIC CATHETER – for genito urinary problem . addtl of 10gms/day for CHON c. egg white (1yr) .meat and table foods . NGT IS REMOVED – if patient exhibits return of bowel sounds. THERAPEUTIC DIET GENERAL CONSIDERATION Know the DIAGNOSIS of the patient Identify & incorporate the pt.egg yolk (6mos).48 hrs – keep balloon inflated for 10 minutes to decrease bleeding LINTON TUBE – 3 lumen – 4 lumen MINESOTTA TUBE SCISSORS – important EQUIPMENT AT BEDSIDE FOR ALL TUBES.keep open to drain urine from kidney pelvis. fruits. BULB SYRINGE – use to clean the nares of pt with NGT (child) To facilitate removal of air at lungs – purpose of water sealed chamber in 3 way bottle system. .never clamp because it can only hold 4-8 ml of urine. HEMOSTAT – important instrument that shld be @ bedside for water sealed drainage.for pt w/ esophageal varices . IRON : 15-30mg/day d. gastric balloon.balloon tamponade .
TRANSCULTURAL CONSIDERATION CHINESE – like cold desserts after surgery for optimum health JEWS – “kosher diet” (no meat and diary products at the same time) EUROPEANS – main meal is served at mid day followed by espresso MUSLIM – “halal diet” – no pork SDA – strictly vegs diet (vit B6 and B12 deficiency) MORMONS – words of wisdom (no caffeine.sparingly MOST COMMON DIET CLEAR LIQUID DIET (light can pass thru it.3-4 FATS . Nephrotic syndrome) to maintain fld & e imbalance LOW CHON – avoid poultry products LOW Na .2-3 FRUITS & Vegs . alcohol and once a month fasting) – the amount due for food is donated to the church KEY POINTS FOR NURSES Sodium (Na) – source down the soil Potassium (K) .avoid processed foods. candy RENAL DIET for kidney disorder (renal failure. & salty foods Low K . milk products and salty foods KNOW the serving: CHO . meaning TRANSPARENT) .given to pt to relieve thirst. popsicle. milk products.given also to pt post-op ex: apple juice.avoid fruits (anything you see in a tree) LOW FAT/CHOLESTEROL RESTRICTED DIET . gelatin (strawberry).6-11 servings CHON . correct fld & electrolyte imbalance .source up the tree Low Na Diet : AVOID processed foods. AGN.
plums & pastries . & corn 3 P’S . vegs and fish AVOID : Sea foods. fruits.prunes. hemorrhoids & diverticulitis . cardiovascular and renal dses ALLOWED: lean meat.vegs. milk products and salty foods BLAND DIET - for peptic ulcer. fresh and raw fruits & vegs (EXCEPT: avocado. fld & e imbalance ALLOWED: fresh vegs AVOID : processed foods. sea foods. HIGH CARBO DIET for burns (about 5000 cal/day) grain products and poultry – to aid the healing tissues ACID ASH DIET to decrease the ph of the urine indicated for pt w/ alkaline stone ex struvite ex. 3 C’S – cranberry. gizzard) NA RESTRICTED DIET for cardiovascular dses. peptic ulcer gastritis pureed foods/ blenderized foods soup PURINE RESTRICTED DIET for gouty arthritis increase fluid intake AVOID: preserved foods. fried foods.. inflammatory GI conditions AVOID: chemically and mechanically irritating foods such as fried foods. organ meat (liver. cheese.to prevent constipation. fruits and grain products SOFT DIET for inflammatory conditions: esophagitis.for liver disorder. banana & pinya) and spicy foods with preservatives HIGH PROTEIN. preserved foods (cheese cake and custard) HIGH FIBER DIET . alcohol. renal.
-Surg – “abc” Psyche .45 PCO2 . rye.safety first Fire . until age 10 and adolescence only AVOID : CHON rich foods (meat products – luncheon meat) FULL LIQUID DIET opaque transitional diet from liquid ex : cream soup.race Triage . leche flan. oats. milk. ALKALINE ASH DIET to increase ph of the urine indicated for acid stone ( uric acid stone. cystine stone) ex.35 – 35 HCO3 . cereals. pumpkin cake “ABGs” ATERIAL BLOOD GASES Ph – 7. wheat PHENYLALANINE DIET for PKU.22 – 26 meq/L Ph Compensatory Mechanism no change increase or decrease increase or decrease Uncompensated abnormal Partially compensated abnormal Fully Compensated normal Diarrhea – metabolic acidosis Vomiting – metabolic alkalosis PRIORITIZING of case: Med.pt evaluation system (prioritizing) APGAR SCORING . corn. soy beans AVOID (LIFETIME): barley.35 – 7. ice cream. Milk GLUTEN-FREE DIET for celiac dses ALLOWED : rice.
direction/communication supervision) RN may delegate – feeding client. pt bp 80/30 & mother died of CVA 1st priority : assess pt for addtl risk factor. airway compromise. cardiac arrest. 2.R. altered level of consciousness. multiple system trauma. Fibrillation) 5. dizziness) TIPS ON PRIORITIZING 1. lacerations. PT @ ER – sleeping pills overdose.I. minor burns. documentation CONCEPT OF DELEGATION consider the competence of personnel 5 R’s in delegating (RIGHT task.E -prioritizing LEVEL 1 “emergency” severe shock. eclampsia LEVEL 2 “urgent (stable)” LEVEL 3 chronic/ minor illness (can be delegated) – dental problems. presence of vent. pt ask what procedure: Rn Action : notify the doctor 4. circumstances.0 Appearance Pulse Grimace Activity Respiratory pallor (-) (-) flaccid (-) 1 2 all pink flexion & extension acrocyanosis <100 >100 grimace vigorous some flexion irregular lusty cry T. MI attack – 1st action : report ASAP (esp. administration. 3. routine medications and chronic low back pain can be delegated (fever. pt on NGT – check patency of tube DELEGATION do not delegate Assessment.G. cervical spine injury. person. Teaching and Evaluation do not delegate meds preparation. routine vital sign (pt w/ no complications) and hygiene care .A.
– independent nsg function know the purpose of the position to prevent or promote soothing. what to prevent or promote.MI ATTACK – enzymes to increase IN ORDER . c.#1 #2 #3 #4 myoglobin troponin CK LDH RISK FOR INJURY – meniere’s dses INEFFECTIVE BREATHING PATTERN – myasthenia gravis ALTERED TISSUE PERFUSION – pt w/ complete heart block INEFFECTIVE AIRWAY CLEARANCE – pt w/ kussmaul’s breathing D DAY 3 ( 02 February 05) POSITIONING FOR SPECIFIC SURGICAL CONDITION Positioning a. b. know your anatomy & physiology – R side lying – to prevent bleeding Post Liver Biopsy .
(during the procedure – L side lying).report ASAP) tingling sensation – indicate nerve damage . (pt say. SHOCK occurs w/in 24-48hrs (immediate post burn phase). e. “I want to go home pain is gone”) BURNS Position is FLAT or Modified Trendelenburg – to prevent shock. AMPUTATION complication: hemorrhage (keep tourniquet @ bedside) 1st 24hr – goal: to decrease edema – elevate the stump at foot part w/ the use of pillow AFTER 24hr – goal : to prevent contracture deformity (keep leg extended) APPENDICITIS Unruptured : any position of comfort Ruptured : semi to high fowler’s position to prevent the upward spread of infection complication: peritonitis Ruptured appendicitis indication: pain decreases or go away. Complication: infection CAST. Hiatal Hernia – upright to prevent reflux. b. d. c. EXTREMITY Elevate the Extremity – to prevent edema (use rubber pillow) Nsg care: a. capillary refill – N 1-3 seconds only (complication: altered circulation) note for s/s of infection (when there is musty odor inside the cast) pruritus (inject air using bulb syringe) blood stained – mark and note (if increasing in diameter .
Supratentorial C – semi fowler’s orlow fowler’s position – to prevent accumulation of fluid at surgical site. b. CRANIOTOMY Types: a. Purpose: same FLAIL CHEST (+) Traumatic Injury – paradoxical chest movement – areas of chest GOES IN inspiration and OUT on Expiration position: towards the affected side to stabilize the chest. GASTRIC RESECTION to prevent dumping syndrome – usually for 10 mos only NOT LIFETIME disorder (post gastrectomy) position : LIE FLAT for 1-2hrs post meal HIATAL HERNIA there is damage to esophageal mucosa what to prevent: gastric reflux therefore FEEP PT IN UPRIGHT POSITION. HIP PROSTHESIS Position: to prevent subloxation (KEEP LEG ABDUCTED) with the use of wedge pillow or triangular pillow from perinium to the knees. Infratentorial C . dumping syndrome : “flat” LAMINECTOMY “log-roll the patient” (3 nurses) – KEEP SPINE IN STRAIGHT ALIGNMENT .flat or supine.
Position pt on the AFFECTED SIDE to promote lung expansion. LIVER BIOPSY before LB : supine or L side lying to expose the part during LB : . blood pressure – ON THE AFFECTED ARM coz there is no more lymph node w/c predispose pt to bleeding. specimen taking. flexionextension (folding of clothing. RADIUM IMPLANT OF THE CERVIX keep pt on complete bed rest to prevent dislodge. L lobe – 2) position : semi fowler’s position – to promote lung expansion MASTECTOMY - removal of breast elevate or extend affected arm to prevent lymp edema (or elevate higher that the level of the heart. AVOIDE SEX (may burn penis bec of the implant inside) RESPIRATORY DISTRESS Adult : Orthopneic position – over bed table then lean forward Pedia : TRIPOD – lean forward and stick out tongue to maximize the Airflow RETINAL DETACHMENT . avoid also gardening and hand sewing PNEUMONECTOMY either L or R lung. vacuuming the house) Due to removal of axillary lymph node. LOBECTOMY removal of Lobe (N R lobe – 3.doafter LB : R side lying w/ small pillow under the coastal margin to prevent bleeding. Post mastectomy Exercises: squeezing exercises. hyperextension and prone – it causes hyperextension of the spine.- AVOID: hyperflexion. AVOID: venipuncture. finger wall climbing. washing face.
” “you’re in the hands of the best” 4.direct question.” In GROUP DISCUSSION – nurse is just a facilitator – let the group decide. If operation is on the R outer of the R eye. place pt on the AFFECTED SIDE.for suicidal pt . AVOID NURSE CENTERED RESPONSE – “I felt same too…” “I had the same feeling…. turn the pt on his abdomen w/ pillow under the subcoastal area. THERAPEUTIC PHRASES – it seems… you seem…. Ex. to maintain the integrity of pt w/ hip prosthesis – abduction splints immediately after supratentorial craniotomy. VEIN STRIPPING keep extremities extended then elevate the legs at level of the heart to promote venous return TIPS liver biopsy is done on a pt. after tonsillectomy – position: prone a pt is about to go on thoracenthesis . place pt on the R position.fowler’s position best position for pt in shock – supine w/ lower extremities elevated THERAPEUTIC COMMUNICATION 1.” 3. when draining the L lower lobe of the lung – the pt shld be positioned on his R side w/ hip higher or slightly higher than the head. position pt on the L side AVOID: sudden head movement. . AVOID PASSING BACK – “I will refer you to….close ended – for manic pt and pt in crisis .- to prevent further detachment.open ended question . DON’T ASK WHY – this put pt on the defensive 2. – during 1st 24hrs after the procedure. he/she channel are concern back to the group.how shld the nurse position the pt? – sitting w/ a arms resting on the overbed table. If operation is on the L inner of the R eye. DON’T GIVE FAKE REASSURANCE – “everything will be alright….
HEPA b – TRANSMITTED BY BLD AND DODY FLUIDS) TIPS: When implementing universal precaution. hats – no sharing Patient with full blown AIDS is placed on isolation precaution – pt ask nurse why his visitors is wearing mask – response: it will help in the prevention of infection.ISOLATION PRECAUTION Purpose : to isolate infection transmission TYPE PRIVATE ROOM HAND WASHING GOWN GLOVE MASK STRICT (airborne dses. head bands. w/c nsg action require intervention: recapping the needle – this might prick your hand. A nurse is giving health teaching to the parents of child with scabies: family member must be treated. . direct contact-Diptheria) RESPIRATORY (AIRBORNE: BEYOND 3FT DROPLET : W/IN 3FT) OPTIONAL OPTIONAL TB CONTACT OPTIONAL (negative airflow room) OPTIONAL (direct contact – NOT AIRBORNE DSES) eX SCABIES ENTERIC (fecal contamination) X OPTIONAL OPTIONAL DISCHARGE X (drainage: pus ex burn pt) UNIVERSAL X OPTIONAL OPTIONAL (AIDS. When discarding the contents of the bed pan use by a pt under enteric precaution – GLOVE IS NECESSARY. Preventing pediculosis in school age children: avoiding contact w/ hair articles of infected children like clips.
2HRS AFTER General anesthesia – keep NPO at least 8hrd after (check gag reflex before meals) • • • • PEDIATRIC PATIENT – use flash cards. if procedures require life threatening – they prefer to have male doctor. pt has the right to refuse procedure. . 1.they only want good news information of their condition DELEGATION and DOCUMENTATION Delegation – assessment. – 24hr urine specimen and urine catheter .they prefer same sex health care provider however. games and play to encourage participation TRANSCULTURAL CONSIDERATION HISPANIC PATIENT – women prefer same gender health care provider Obtain help of interpreter when explaining procedures – (except or don’t ask family members) For muslim patient . doctor the one who asked for consent Check pt for CONSENT – if INVASIVE – WITH CONSENT NON INVASIVE – NO CONSENT needed CONTRAST MEDIUM – check for allergy For procedure requiring anesthesia – KEEP PT NPO B4 PROCEDURE When local anesthesia used – NPO. Essential when a pt w/ meningitis is kept in isolation: isolation precaution remains until 24hrs after initiating antibiotic therapy DIAGNOSTIC PROCEDURES side notes: pt for IVP pt for KUB schilling test USG : : : : assess for allergy (cleansing enema b4 the procedure) no dye (don’t assess for allergy) 24hr urine specimen no consent required GENERAL CONSIDERATION • - EXPLAIN the procedure to the pt (initial nsg action) if not ready inform the doctor. monitoring and evaluation of treatment (cannot be delegated) BUT standard and changing procedures can be delegated ex.
CONTRACTION STRESS TEST (oxytocin challenge test) HOW: Thru breast stimulation – it triggers the release of oxytocin from pituitary gland… If (-) patient is given Oxytocin – onset is 20-30 minutes. Monitor for adverse reaction. NST is (+) if FHR increase at least 15 beats/min than the baseline. ring a bell b. Documentation – type of treatment and any untoward reactions. early deceleration – indicates head compression (MIRROR IMAGE) correlates FHR with uterine contractions pt on NPO get baseline FHR then induce uterine contraction b. feed the patient then check FHR. Treat Hypotenson c. Administer O2. 140 FHB baseline. Special Consideration and Interpretation DIAGNOSTIC TESTS (to evaluate FETAL GROWTH AND WELL-BEING) DAILY FETAL MOVEMENT Purpose : to determine fetal activity by counting fetal movements – usually perform by pt himself N Fetal Movement 10-12 for 12 hr period (average: 1 movement/hr with average 3fm/hr) NON STRESS TEST (NST) – correlates fetal heart rate w/ fetal movement monitor the baseline FHR then induce fetal movements by (HOW) : a. Then check FHR and note the presence of DECELERATION (slowing of FHR) types of deceleration a. Report complication to the doctor FRAMEWORK – includes the Purpose. variable deceleration – due to cord (image: U or W shape) and slowing of FHR can occur anytime. (ex.collection. KEYPOINTS FOR NURSES Prepare the patient. then after challenge it increase to 155) POSITIVE result means. BABY is REACTIVE (good condition) and no need for contraction stress test/oxytocin challenge test – coz baby is OK and doing well. late deceleration – indicates placental insufficiency (REVERSE MIRROR IMAGE) mgt: L Lateral Recumbent Position. .
indicates fetal jeopardy ULTRASOUND .NPO . of danger abortion (assess pt age of gestation) or can be done on the 3rd wk (34-36 wk) purpose: to detect fetal maturity (FLM) thru monitoring of L/S Ratio N 2:1 (if mother is (+) DM LS ratio is 3:1) This procedure also check level of alpha-feto Protein – if INCREASE – spina befida. & presence of RH Incompatibility Extract blood at umbilical cord then it is tested if it really comes from the umbilical cord (can be done on either 2nd or 3rd tri. BIOPHYSICAL PROFILE – to determine fetal well being w/ the use of 5 CRITERIA 2 points 2 points 2 points 2 points 2 points 10 points fetal breathing movement heart tone reaction to NST amniotic fld volume score below 6.If (+) CST. Trisomy 21) Done in 1st trimester (can be done as early as 5th wk but can be done on 8-10th wk) AMNIO Purpose : same w/ CVS PUBS Purpose: to check chromosomal aberrations. Upper USG – NPO b.for pregnant: site is lower abdominal USG types: a.provide data on placenta (age and location) gender of baby structural abnormalities position of baby . Down syndrome.preparation: increase fluid intake (oral) NO consent needed If pt ask if it is painful: NO PAIN. can be done on the 2nd wk (14-16 wk) . get some sample) (+) Consent – invasive Bladder : Empty (+) Consent consider the Pt Age of Gestation (if age of gestation : (+) Consent . baby is NOT OK coz there is decrease FHR and during labor he/she may stand the labor process. meaning there is deceleration.but not recommended bec. Lower USG . Pt shld have full bladder CHORIONIC VILLI SAMPLING – CVS AMNIOCENTESIS – AMNIO PERCUTANEOUS UMBILICAL CORD BLOOD SAMPLING – PUBS CVS Purpose: to detect chromosomal Aberration (eg. If DECRTEASE – down syndrome Get sample at chorion (by 10-12wks – The placenta matures.
c. gluten free diet will be for life time) . nasal airflow and O2 saturation – N 95-98% below 85 – report ASAP GLUTEN CHALLENGE .pt is given gluten rich food for 3-4 months the observe s/s of CD s/s of CD: abdl cramps. if AOG is 20wks and below : full bladder COMPLICATIONS of CVS. RR. b. infection bleeding abortion fetal death TIPS • EARLY DECELERATION – expected in the fetal monitor when there is fetal head compression. AMNIO & PUBS: a. abdl rigidity. d. • A mother asked the nurse what will amniocentesis provide during pregnancy: it will show as whether the baby lungs are developed enough for the baby to be born. steatorrhea. • after amniocentesis w/c of the following manifestation if observed by the nurse on the patient that needs to be reported : bleeding. abdl distention (if + for CD.intolerance to gluten. • AMNIOCENTESIS – was done @ 35 wks gestation – purpose: to determine fetal lung maturity. • a nurse is preparing pt for lower abdl usg – w/c of the following done by the pt needs further teaching – pt voids b4 the procedure. what to check – USG DEVICE DIAGNOSTIC TESTS (to evaluate pediatric patients) CARDIOPNEUMOGRAM – use to diagnose apnea of infancy – assess HR. . • pt ask the nurse – what deceleration means – it refers to slowing of baby’s before Amniocentesis.is higher than 20wks and above : empty bladder.detect presence of Celiac Disease (CD) . • heart rate.
(+) scoliosis – if presence of rib hump. 8mg/dl – confirms PKU) .PH) Phenylalamine hydroxylase – is an enzyme that converts PH to Tyroxine – the one that gives color to hair. if sickling of RBC Therefore TRAIT CARRIER (S or C shape RBC). no one will convert PH to Tyroxine. HOLD CAFFEINE FOOD – 2days b4 test SCOLIOMETER measure the degree or angle of scoliosis check for: (+) scoliosis if uneven hemline uneven waist more prominent iliac rest and scapula on one side presence of rib hump test for pre-teen : “bend over test” – bend and touch the toe. check for apnea of infancy preparation : No Special prep.ORTOLANI’S TEST (OT) purpose: test developmental dysplacia of the hip or congenital hip dislocation (+) if w/ click sound (lateral) BARLOW’S MANUEVER (BM) purpose : same (+) barlow’s click – press downward and w/ click sound POLYSOMNOGRAPHY or “sleep test” EEG is connected to pt when he sleeps Check the brain waves. therefore it will accumulates to brain and can cause mental retardation. so give CHON food first for 3wks then retest. At birth. Before test. it is usually negative. eyes and skin. if (+) TURBID Specimen : Blood : bld + electropoiesis.to detect PKU (in PKU there is absence of PHENYLALAMINE HYDROXYLASE. If absent PH. therefore + for SC Dses Test for TRAIT Test for Disease GUTHRIE CAPILLARY BLOOD TEST (GCBT) .>2mg/dl (if 4mg/dl – indicative of PKU. therefore x-ray then scoliometer. SICKLEDEX TEST Purpose: test for sickle cell anemia HGB ELECTROPOISIS Purpose: test for sickle cell anemia Specimen : Blood : (blood + solution. give chon rich food for 1-4 days before test. PH came from CHON rich food. (adult) N PH level .
meaning cannot reabsorb Na and it accumulates outside of the skin). TIPS pt w/ PKU would more likely to have (+) result in gluten capillary bld test if there is – adequate CHON in the diet.SWEAT CHLORIDE TEST Types: a. ELECTROCARDIOGRAPHY – records the electrical activity of the HEART P wave – atrial depolarization QRS complex – ventricular depolarization ST . serum chloride test – N 90-110 meq/L (above 140 meq/L – (+) to detect Cystic Fibrosis (in CF. hgb electropoisis – test for sickle cell dses DAY 4 (3 Feb 2005) DIAGNOSTIC PROCEDURES I.repolarization Rhythm – appearance of wave and distance Rate .N 60-100 bpm – check on # of QRS then divide it by 300 (k) ABNORMALITIES . 9 yo pt has (+) result for sweat test – this indicates possible dx of Cystic Fibrosis. sweat chloride test – N 10-35 meq/L (above 40 meq/L– (+) b. Mother complain that her baby taste salty. pilocarpine – drug used for pt undergoing seat chloride test. PILOCARPINE – used in the test to induce sweating. CARDIOVASCULAR A. the skin becomes impermeable to Na. mother complains that her baby taste salty – which test is to be performed : sweat chloride test.
Bld products. arrythimia “EBA” nsg mgt : monitor distal pulses (if brachial site: check @ radial if femoral site : check @ dorsalis pedis) if weak or no pulse – REPORT if (+) bleeding – report (“sandbag 10-20 lbs” – shld be at bedside) C.st segment elevation or depression. atrial fibrillation – p waves “halos magkadikit. Pulmonary Artery Pressure. (no discernable p waves) b. femoral.12) ANGINA – st segment elevation. brachial common complications: embolism. SWAN-GANZ CATHETERIZATION 4 lumen for the ff CVP. Pulmonary Capillary Wedge Pressure (PCWP).. atrial flutter – “saw tooth” flutter waves c. bleeding. STRESS TEST determines the ability of the heart to withstand stress equipment : threadmill & ECG nsg alert : check pulse and BP keep NPO an hr b4 the test NO Jewelries D. Balloon CVP – measure R side pressure of the heart PCWP – L side of the heart N Pressure CVP: for R Atrium – 0-12 . t wave inversion B.8-. CORONARY ARTERIOGRAPHY visualization of the bld vessels w/ contrast medium nsg alert: (+)consent check allergy to contrast medium increase oral fluid intake after to excrete dye epinephrine shld be ready for any untoward reaction E.a. ventricular – check on QRS (N . t wave inversion MI . CARDIAC CATHETERIZATION it determine the structural abnormalities in the heart either L or R sided catheterization site: antecubital.
5-1. hypokalemia – “FLD VOL. EXCESS” POTASSIUM (3.5) most sensitive index of kidney funx (increase BUN but N creatinine – do not report to AP) increase creatinine – kidney failure or renal disorder BUN (10-20 mg/dl) inc.5 – 5 meq/L) Hyperkalemia : Addison’s dses Hypokalemia : Cushing Syndrome Inc or dec in K PT RISK of INJURY Pt w/ digitalis & diuretics – monitor for arrhythmia CALCIUM (4.for SVC – 5-12 Nsg Alert : check pulse and s/s of bleeding F. if (+) kidney disorder LDH (40 – 90 u/L) LDH1 – 27-37% (for heart – check for MI) LDH2 – 17-27% (for heart – check for MI) LDH3 – 8-15% (for respiratory system) LDH4 – 3-8% (for liver & kidney) LDH5 – 0-5% (for liver & kidney) LDH inc for MI for 3-4 days then it returns to N after 10-14 days . hyperkalemia (inc K) – “FLD IMBALANCE” Cushing Syndrome: hypernatremia.5 – 5 meq/L or 9-10mg/dl) Hyperthyroidism – inc CA Renal Calculi Formation – inc CA @ bld GLUCOSE (80-120) Higher than 140 – hyperglycemia (acidosis – may lead to ineffective breathing pattern and airway is the main problem) below 50 – hypoglycemia (pt prone to injury & altered thought process) Creatinine (. BLOOD CHEMISTRIES SODIUM (135 – 145 meq/L) Addison’s Dses: hyponatremia (dec Na).
10-55 u/L Increase CPK 3-6hrs post MI then it normalize 3-4 dyas AST (SGOT) .000-450. HEMATOLOGIC STUDIES RBC (4.inc WBC – hyperleukocytosis – (+) to pt w/ leukemia – risk for infxn PLATELET (150.35-45% .to detect presence of infection. for liver dses) SGPT (ALT) N 8-20 u/L more on HEART (inc for cardiac dses) G. non invasive. CPK or CK Male – 12-70 u/L Female .5 million) .dec RBC – anemia – activity intolerance WBC (5-10 thousand) .spontaneous bleeding occurs when platelet dec (pt also prone to injury) PT (11-12 sec) PTT (60-70 sec) APTT (30-40 sec) coumadin – check pt monitor pt 4 bleeding heparin – PTT monitor pt 4 bleeding HGB – male : 14-18 mg/dl Female : 12-16 mg/dl Dec hgb – anemia (nsg dx: activity intolerance) HCT .painless.determine the adequacy of hydration and the ration of plasma to the cellular component blood inc hct dec hct : hemoconcentration (nsg dx: fld deficit – dehydrated pt) : hemodilution fld excess DOPPLER USG .5 – 5.inc RBC – polycythemia – risk for injury – complication CVA . NO SMOKING 30 min-1hr b4 the test .to detect the patency of bld vessels – arteries & veins esp of lower extremities.000) . . bld disorders like leukemia .for liver (inc.N 8-20 u/L .dec WBC – pt prone to infection .
no preparation. Pt may expect a sore feeling (PINK STINGED SPUTUM) Report (+) stridor CHEST X-RAY - to determine abnormalities of lungs and thoracic cavity. color.thru the use of incentive spirometer .rusty . abnormal particles.blood streaked - BRONCHITIS .N 95-98 – attach to finger or earlobe (do not expose e light) II. ABSOLUTE CONTRAINDICATED TO PREGNANCY Check pt for radiation indicator Determine effectiveness of tx and whether pt is active or non-active SPUTUM STUDIES to determine the gross characteristic of the sputum (refers to the amount. to gather specimen for biopsy.determines the O2 saturation at blood .affected or unaffected side position: Nsg alert: NO COUGHING & DEEP BREATHING – during the procedure – coz this may cause puncture of the lungs. consistency and characteristic) TYPE OF SPUTUM PNEUMONIA TB .aspiration of fld at thoracic cavity (for diagnostic & therapeutic purpose) DURING – sitting AFTER . tree or airway passages.PULSE OXIMETRY .gelatinous CHF/ PULMONARY EDEMA . Complication: bleeding and pneumothorax PULMONARY FUNCTION TEST . NPO b4 & after Gag reflex return after 1-2hrs.pink stinged Sputum specimen – sterile container THORACENTESIS .vital capacity (4-5 L of air) – refers 2 N amt of air that goes in . RESPIRATORY BRONCHOSCOPY – – – – – – visualization of b.Viral – thin & watery Bacteria . Assess for breath sounds after.
. BEVEL UP then read 48-72hrs after 5mm in duration – (+) for HIV. (detect cancer and tumor) also to detect O2 saturation @ tissue.using PPD (purified chon derivatives) . HOLD then EXHALE LUNG SCAN .angle 10-15.(+) consent. previously (+) pt. .assess for rxn to allergy MANTOUX TEST . anti-convulsant. children below 3yo and for pt w/ medical condition – DM & Alcoholism 15mm .with contrast medium. space occupying lessions alcohol brain waves and seizures nursing alert: dietary modification: WITHOLD CAFFEINE – coffee and tea. sedatives.aspiration of tissues at lungs for dx of tumors. (-) consent detect the ff: brain tumors. malignancy .test for POSSIBLE TB EXPOSURE.assess for bleeding. alcohol - CT SCAN MRI PET Use radiation to determine use electromagnetic field use gamma rays or positron electron tissue density to detect abnormality of tissue density to detect abnormality of tissue density. multiple sex.to identify the presence of blockage in the pulmonary bld vessels. WITHOLD 48hrs b4 the procedure : tranquilizers. 10mm .(+) for general population LUNG BIOPSY . . .(+) for immigrants. breath sounds & report for s/s of dyspnea III. . NERVOUS EEG shampoo hair B4 (to remove chemicals) and AFTER to remove electrode gel (shampoo or acetone) measures electrical activity of the brain (gray matter) non invasive. PROCEDURE: EXHALE then INSERT mouth piece. BREATH iN.& out of lung after maximum inspiration.
keep pt NPO.. Measurement of blocked artery) like CA Tx NSG ALERT: (w/ or w/out dye) CONTRAINDICATION a. claustrophobia (give anti-anxiety b4) pt w/ unstable v/s (arrhythmic & HPN). CSF ANALYSIS Assess for the characteristic of CSF. c. pregnancy. Na and H2O . b. and to evaluate tx give more detailed impression (ex. obese pt (more than 300 lbs). keep epinephrine and or benadryl at bedside for emergency - LUMBAR PUNCTURE aspiration of CSF for assessment to check for infection or hemorrhage position: DURING : fetal or C-position AFTER : FLAT to prevent spinal headache Needle is inserted between L3 and L4 or L4 and L5 Increase fluid intake after. d. pt w/ allergy to dye CONTRAINDICATION (same w/ ct scan BUT w/ addtl) NO METAL OBJECTS . CONTRAINDICATED IN: pt w/ allergy. insulin pump. pacemaker. N amount: 100-200 ml Characteristic : Clear w/ glucose. e. hip replacement b. e. bleeding Nursing Alert: a. assess pt for allergy.jewelries.physiology of psychosis. “clicking sound” will be heard & lie still during the procedure lie still lie still during the procedure and “thumping sound” will be heard - CEREBRAL ANGIOGRAM involves visualization of bld vessels @ vein w/ the use of contrast medium. pregnant pt. d. c. monitor for signs of bldg. inc oral fld intake to excrete dye.
- MYELOGRAM test for presence of slip disc or herniated nucleus porposus (HNP). FLAT after Rationale for both oil and water based dye is TO PREVENT the upward dispersal of dye w/c can cause electrical meningitis (s/s includes: (+) seizure.If REDDISH – hemorrhage If Yellowish – infection Ear licking w/ fluid – test if (+) glucose bec. SEVERE NYSTAGMUS – NORMAL MODERATE NYS . water based – called AMIPAQUE b. If water based. . the HEAD OF BED ELEVATED. headache) IV.Minierre’s Dses NO NYSTAGMUS . EENT • TONOMETRY to measure IOP (N 12-21) . oil base – called PANTOPAQUE type of dye will determine the position of pt AFTER the procedure.Acoustic Neuroma • GONIOSCOPY to differentiate OPEN and close angle galucoma. ALERT: Know the type of dye use: a.painless but w/ local anesthesia ACUTE GLUACOMA : 50 yo and above CHRONIC GALUCOMA : 25 yo • CALORIC STIMULATION TEST test the presence of Minierre’s Dses (inner ear) involves introduction of warm and cold water then NOTE FOR NYSTAGMUS – jerky lateral movement of the eye. If oil based. CSF has glucose.
Contrast Medium: a. if pt hear better in POOR EAR. . - GASTRO INTESTINAL TRACT UPPER GI SERIES (Barium Swallow) xray visualization with contrast medium . therefore CONDUCTIVE HEARING LOSS V.refers to if AIR CONDUCTION is LONGER. therefore CONDUCTIVE HEARING LOSS SENSORINEURAL HEARING LOSS. Gastrografin – water soluble. diverculosis. If BONE CONDUCTION IS LONGER. give laxative to excrete dye (bec dye is constipating) instruct also patient to inc oral fld intake - GUAIAC TEST to detect the presence of bleeding and inflammatory bowel condition like CANCER. there is balloon catheter inserted @ anus then barium is instilled and pt is asked to roll-over at different position then xray is taken to detect: hemorrhoids. Fish and Horse Radish CHOLANGIOGRAPHY . To determine air and bone conduction If pt hears vibration better in GOOD EAR.swallow – milk shake like (use feeding bottle of pt) . (this can be refrigerated awaiting laboratory) specimen : stool AVOID the following 3 days B4 the test – bec it can yield to FALSE (+) RESULT : Red Meat. place at mastoid bone or in teeth then…. polyps and lesions. after.- non-invasive. Barium .then pt is ask to assume different positions to distribute dye @ esophagus purpose: to detect disorders of esophagus feces : “chalky-white” after: instruct pt to take laxative to excrete dye BARIUM ENEMA (for Lower GIT) involve rectal installation of barium. use straw b. Place tuning fork 2inches from the ear Problem would be SENSORINEURAL LOSS. painless RINNE’S TEST WEBER TEST To determine lateralization of sound.
therefore Gastric CA. hepatic duct & common bile duct) – same with CHOLECYSTOGRAPY – but medium given orally. if Increase HCL Acid – therefore ZOLLINGER-ELLISON SYNDROME – (+) Gastric Tumor b. . WITH TUBE – with the use of NGT then aspirate ULTRASONOGRAPHY upper abdl USG to detect abnormalities in the upper abdl area w/ includes biliary tree and Upper GI. if urine (-) blue color.- visualization of biliary tree (includes. if urine colors turns BLUE. gel at abdomen and pt is NPO LIVER BIOPSY aspiration of sample tissue from the liver to detect: Hepatic CA and Cirrhosis. therefore (-) HCL Acid - if (-) HCL Acid at stomach (achlorhydia). WITHOUT TUBE (tubeless gastric analysis) - using DIAGNEX BLUE (specimen: urine). therefore (+) HCL Acid. oral fld intake – to facilitate excretion of dye GASTRIC ANALYSIS analysis of gastric secretion like HYDROCHLORIC ACID Lower Level N : 2-5 meq/hr Upper Limit N: 10-20 meq/hr UPPER LIMIT YPES a. ALERT: Check for Bleeding Time (N – 1-9 mins) and Clotting Time (N – 10-12 mins) – because liver is highly vascular organ WHEN NEDDLE IS INSERTED tell pt to: Inhale then Exhale then Hold Breath – to stabilize liver position Position after : R side-lying position Things to report: s/s of SHOCK – inc PR. dec BP Check v/s - ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP) to visualize common bile duct and pancreatic duct. invasive – (+) consent. painless. with contrast medium w/s is given thru IV ALERT: assess for allergy (epinephrine/benadryl) Post procedure: inc.
NPO – tube insertion; Tell pt that tere will be feeling of soreness a wk after the procedure
COLONOSCOPY visualization of colon to detect: inflammatory bowel condition Chron’s Dses Diverticulitis Hemmorhoids Tumor Polyps
- (+) Consent - NPO b4 - clear liquid diet – 2days b4 the procedure position: Lateral or side lying position or L Lateral Sims
GLUCOSE TOLERANCE TEST to provide measure of bld sugar level at blood; Inform pt to have high CHO diet 2 days b4 the test; Instruct NPO a day b4 the test (npo post midnoc); Inc sugar level, therefore Diabetes
ACTH STIMULATION TEST to detect presence of Addison’s Dses specimen: blood pt is given dose of ACTH (not nore than 40ug/dl) if still dec despite ACTH administration, therefore Adrenal Insufficiency – Addison’s Dses
DEXAMETHASONE SUPRESSION TEST to detect endogenous depression – depression resulting thru endocrine disorder pt is given dexa then 24hr urine specimen is collected; a dose of dexa will suppress the release of adrenal hormones; if despite dexa administration still increase adrenal hormones, therefore pt is suffering depression
17 KETOSTEROID & 170 HCS use to detect the presence of Addison’s & Cushing’s Dses.
Addison’s – dec secretion of ketones Cushing’s – ince secretion of ketones Specimen: 24 hr urine
VANILLYLMANDELIC ACID TEST – VMA Test bi-product of CATHECHOLAMINE Metabolism
inc if there is TUMOR (pheocromocytoma) of Adrenal Medulla
N 2-7 mg/dl / 24hrs – if inc, therefore tumor AVOID: vanilla containing food 3 days b4 test – RAIU pt is given iodine 131 then after 24hr followed by a thyroid scan inc indicates hyperthyroidism, dec hypothyroidism AVOID: iodine rich-food (sea foods, sea shells, sea weeds) 7-10 days b4 and to include other diagnostic procedures that uses contrast medium (“NO” - angiogram test). – bec it may yield to false (-) result. SULKOWITCH’S TEST detect amount of calcium excreted at urine; if to test for hypercalcemia and hyperthyroidism - gather specimen b4 meals; to test for hypocalcemia and hypothyroidism – gather after meals ice cream, coffee, chocolates
VII. R E NA L
URINALYSIS examine the gross characteristic of the urine
urine amount : 30-60ml/hr color : clear, amber s. gravity : 1.010 – 1.025
abnormality: lower than 1.005 – diabetic insipidus higher than 1.030 – diabetic mellitus (+) glucose – infection, DM (+) CHON - PIH, kidney dses. Urine maybe refrigerated if waiting to be examined.
CULTURE & SENSITIVITY to detect infection prepare storage container
KUB xray of the kidneys, ureter and bladder - NO SPECIAL PREPARATION NEEDED
- xray of the kidneys, ureter and bladder - uses contrast medium/ dye - assess for allergy, then inc. oral fld intake after - benadryl or epinephrine at bedside for allergic rxn - NPO POST MIDNOC, cleansing enema in AM
CYSTOSCOPY visualization of urinary bladder after : monitor I & O; note for s/s of bleeding
RENAL BIOPSY aspiration of tissues at kidney for biopsy to detect: a. malignancy/ Ca b. malignant HPN c. kidney disorder note for s/s of bleeding
CYSTOURETROGRAM to check the patency of the ureter and bladder; monitor I & O
CYSTOMETROGRAM to evaluate the sensory and motor funx of bladder; to check if bladder respond to distention after installation of flds; monitor I & O
ELECTROMYOGRAPHY to detect electrical activity of the muscle; (+) consent; to alternately contract and release the muscle as needle is inserted HOLD muscle relaxant b4 the test
ARTHROCENTESIS aspiration of fluids at synovial space to detect abnormalities; check for order of analgesic; apply cold pack
stand erect. pt is given oral VIT B12 then urine is collected. marrow (eg. eg. URINE UROBILINOGEN to detect HEMOLYTIC DSES WITHOLD ALL MEDS – 24hrs b4 the test BENCE-JONES PROTEIN detect presence of MULTIPLE MYELOMA (malignancy of plasma cells).KEEP TORNIQUET. Leukemia) site : ILEAC REST (+) consent assess for bleeding sand bag at bedside (post procedure) – for emergency use SCHILLING’S TEST specimen: 24hr urine test for VIT B12 deficiency. for pt w/ PERNICIOUS ANEMEIA. ICE PACK and ANALGESIC at bedside BONE SCAN detect rate of bone destruction or bone resorption for pt w/ osteoporosis. MISCELLANEOUS BONE MARROW BIOPSY to check abnormalities at the b. ARTHROSCOPY . therefore TUMOR at cerebellum) (if pt is ERYTHROCYTE FRAGILITY TEST use to detect the rate of RBC DESTRUCTION in a hypotonic . RELEASED by destroyed or damage bones ROMBERG’S TEST check FUNX of CEREBELLUM. and observe for inability to maintain posture Swaying. PAINLESS AND NON INVASIVE IX.visualization of joints . lie still during the procedure. then NOTE for RATE of EXCRETION of VIT B12 (N – less than 40%). If 100mg Vit b was taken – 60mg shld retain at stomach and 40mg will be excreted. close eyes.
Pt w/ coronary angiogram.solution (RBC Lifespan: 120 days) if lifespan of RBC >120 days. In explaining to the pt about cystoscopy the nurse shld say : the bladder lining will be visualize. . Treatment: tetracycline causative agent of lyme’s TIPS FOR DIAGNOSTIC PROCEDURE 2 moths old infant suspected of brocholitis is treated with oxygen therapy. After liver biopsy. Which result indicates that tx was effective : 02 SATURATION OF 98%. Staff nurse is observing a nurse caring for pt w/ cvp. a potential complication: bleeding. W/c action of the nurse require intervention? – touching the edge of the soiled dressing using clean gloves. w/c intervention is appropriate after the procedure: palpate the popliteal and pedal pulses. A pt is to have an upper GI series – which statement shows that he understood the instruction given : “I will drink the dye”. Pt undergoing ERCP – important prep for nurse to make would be: keep pt NPO b4 the procedure. w/c responses made by the pt indicates that he understands the procedure to be done in a CT scan: “a dye will be injected to me”. the catheter was inserted at the L femoral artery. SICKLE CELL) HETEROPHIL ANTIBODY TEST detect presence of IgM w/c is related to Epstein Virus infection Epstein Virus Infection – causative agent of infectious mononucleousis (“kissing dses”) mgt: AVOID SHARING of utensils and glass LYMES DSES SEROLOGY detect presence of BORRELIA BURGDORFERI – dses. MRI is the primary diagnostic tool for multiple scelosis bec it promotes visualization of plaques at the brain. What shld the nurse instruct pt to do during needle insertion? hold breath during the procedure upon insertion of the needle. Pt is scheduled for liver biopsy. w/c of the ff will yield an accurate reading of CVP: when the zero level of the manometer is at the level of R atrium. A mantoux test is (+) – if the nurse assesses w/c of the following: in duration. therefore HEMOLYTIC ANEMIA (EX.
LITHIUM – if above 65 yo.0mEq b. shld not 50 mg II. MEPERIDINE – if above 65 yo.DAY 5 (8 Feb 2005) PHARMACOLOGY I. TRANSCULTURAL ASIANS – are stoicism attitude MIDDLE EASTERNERS (they refuse meds if for the 1st time) they expect meds during first contact w/ hx care provider JEWISH – no meds restrictions JEHOVAH’S WITNESS – do ORIENTAL PAYLOAH (from mexico) . ELDERLY PT – provide with memory aid PEDIATRIC PT – do not mix w/ milk (dosage depends on wt. dose shld not more than 6mg/day c. age and size) For SIDE EFFECTS – GI symptoms (mostly) For AD. dose shld not more than 1. EFFECTS – always consider bone marrow (“leukocytopenia – all PENIA”) 3 COMMON DRUGS – with patients over 65 y/o a. HALDOL – if above 65 yo. GENERAL CONSIDERATIONS • • • • • • ONLY RN’s are allowed to administer (to include central line) LPN’s – peripheral IV Line route.
THE CHECK PRINCIPLE C– HECKlassification (FOR WHAT?) ow will you know that he meds if effective (evaluation) xactly what time are you going to give it lient teaching tips eys to giving it safely Lactulose – given to pt with hepatic enceph to dec ammonia absorption . Photosensitivity (use sunscreen when outdoors) LITHIUM – shld have inc. with cancer ST JOHN’S WORT . treatment.blood thinner.for pt w/ alzeimers .for pt. dosage and untoward reaction. documentation of meds . NO HERBAL to lactating pt. route. .sedative (used also as anti-anxiety agent) . . administration.s/e : diarrhea ANTABUSE (dizulfiram) – most appropriate time to take meds : after 12hrs of alcohol free. . treatment for diarrhea. fluid in the diet III. . NO HERBAL for those with severe kidney and liver disorder IV.anti-depressant (it funx like MAO inhibitor). DELEGATION AND DOCUMENTATION Document all medical admin record: The following CANNOT be delegated: time.do not give to pt taking MAO VALERIAN .use to boost the immune system.CONTRAINDICATED to pt with bleeding disorders COMMON CONTRAINDICATIONS for HERBAL MEDS: NO HERBAL MEDS for pregnant client.can cause staining of teeth. COGENTIN – to prevent pseudoparkinsonism (by decreasing muscle rigidity) TETRACYCLINE .adverse effects – GI Irritation GINGCO BILOBA .use to enhance bld circulation. may cause lead toxicity ECHINECEA .
HALUCINATION . body malaise c. Dantrium ex. sore throat d. mask-like face or expressionless face b. Signs & Symptoms: a. Assess SIGNS and SYMPTOMS of PSEUDOPARKINSONISM a. chills hyperpyrexia and muscle rigidity this indicates NEUROLEPTIC MALIGNANT SYNDROME (NMS) drug of choice: Parlodel. DELUSION – “FALSE BELIEF” b.hearing sounds c. for SCHIZOPHRENIA (pt has EXCESS DOPAMINE). cogwheel’s rigidity or lead pipe rigidity AKATHESIA – “restless leg syndrome” (I feel as if I have ants in my pants) DYSTONIA Avoid direct sunlight – because meds photosensitivity Instruct pt to rise slowly – to avoid orthostatic hypotension . LOOSENES OF ASSOCIATION – shifting of topic CLIENT TEACHINGS: Report ADVERSE EFFECTS of ANTI-PSYCHOTICS – which indicates agranulocytosis a. ANTIPSYCHOTIC major tranquilizer. pill-rolling tremors c.PSYCHOTROPIC I. plays as treatment to the symptoms NOT CURE to schizo – meaning it modify the symptoms (target symptom: to decrease dopamine) Haldol Chlorpromazine Clozapine (chlozaril) Olanzapine (zyprexa) Risperdon BETS TO GIVE: after meals DOPAMINE – neurotransmitter (facilitate the transmission of neurons) In SCHIZO there in INCREASE NEUROTANSMITTER. fever b.
ECG II. roughage at diet. Tranxene Effective: Decrease Anxiety. AST/ALT To prevent pseudoparkinsonism. Librium. Health Teachings: a. urinary retention NOT urinary frequency decrease BP – rise slowly check BP. dietary modification: AVOID CHON and Vit B6 . PR. f. When to give: AFTER MEALS.ANTIPARKINSONIAN in schizo there is increase dopamine. side effects: blurred vision (no driving). Therefore give dopaminergic. Benadry Cogentin effective: if decrease tremors and rigidity. Valium. DOPAMINERGICS . ANTICHOLINERGIC decrease ACETYLCHOLINE ex.bec it decreases drug absorption b. constipation – inc. b.Check: CBC. when to give: AFTER MEALS. diazepam. dry mouth – suck on ice chips or hard candy. ex. therefore give antipsychotic to dec dopamine then dec dopamine causes pseudoparkinsonism. Decrease Muscle Spasm Promote Sleep (to pt w/ traction) B4 MEALS – because food delays absorption HEALTH TEACHINGS: . c. d. c. g. check BP and PR IB. administer ANTIPARKINSONIAN agents IA. L-Dopa Levodopa Levodopa-Carbidopa Effective if decrease in tremors and rigidity within 2-3 days. check for ORTHOSTATIC HYPOTENSION and PALPITATION. Health Teachings: a. BP. palpitations – check PR. ANTI-ANXIETY minor tranquilizer decrease Reticular Activity System – center of wakefulness ex. e.
administer VALIUM separately – because it is incompatible with any drug – use different syringe. c. b. Danger of Dependency c. report ADVERSE EFFECT: PARADOXICAL REACTION – opposite of side effects b. TRICYCLICS – prevents the reabsorption of norepinephrine. Nardil and Marplan Effective : if INCREASE SLEEP and APPETITE – Give AFTER MEALS Hx Teachings: AVOID – TYRAMINE CONTAINING FOOD (1 day before FIRST DOSE and 14 days AFTER LAST DOSE) . III. Parnate. Alcohol – it increase the depressant effect of the drug d. Tofranil. Ex. MAO INHIBITOR (MonoAmine Oxidase) prevents the destruction of NEUROTRANSMITTERs ex.a. d. ANTI-DEPRESSANT/MANIC a. AVOID: Caffeine. Elavil Effective: If adequate sleep (8hrs only) Increase appetite AFTER MEALS Best given: Hx Teachings: The INITIAL EFFECT 2-3 wks after FULL THERAPEUTIC EFFCET 3-4 wks ONSET EFFECT in a WK AVOID : juice – because an acidic medium decrease absorption of drugs REPORT PALPITATION and TACHYCARDIA and ARRYTHMIAS – adverse effects of TRICYCLICS CHECK BP and ECG B. check RR – it causes respiratory depression e. TRICYCLICS MAO STIMULANTS SSRI PATIENT with DEPRESSION – there is DECREASE norepinephrine and serotonin A.
it causes INSOMNIA – 6 Hrs b4 bedtime.Avocado. give NOT BEYOND 2pm bec. Prozac Adverse effects: s/e: DECREASE LIBIDO and Impotence GI III. ZOLOFT. FRESH MEAT. banana. aged and swiss) COLA. SSRI (selective serotonin reuptake inhibitor) Ex. cheese (cheddar.1 ANTIMANIC Lithium (lithane. escalith) Tegretol Depakine/ Depakote . Dexedrine and Cylert) - directly stimulates the CNS. after MAO – 2 wks rest then can give ST JOHN’S WORT C. check BP and PR D. CHICKEN LIVER SOY SAUCE RED WINE PICKLES ALLOWED: cheese – cottage and cream. Effective: Increase Appetite and Adequate sleep Best to Give: AFTER MEALS if b4 meals. STIMULANTS (Ritalin. it suppresses the appetite. shld be given in the morning – to avoid INSOMNIA COMPLICATIONS: growth suppression Hx Teachings: provide intervals or intermittently to avoid growth suppression. VEGETABLES Check BP – the drug can cause HYPERTENSIVE CRISIS – occipital headache – “my nape is aching” 2 WKS INTERVAL – when shifting ANTI DEPRESSANT – to avoid HYPERTENSIVE CRISIS ex . lithobid.
0 mEq/L MAINTENANCE DOSE .A.4 .8 mEq/L Lithium is effective with 10 – 14 DAYS before it will reach its therapeutic level.if above s/s are (+) to patient.. DOPAKINE/ DEPAKOTE tegretol – a/e : alopecia dopakine/ depakote . CONTRAINDICATION OF LITHIUM: • • • Pregnancy. Avoid caffeine.gingivitis ANTICONVULSANT (Tegretol and dilantin) for seizures. Monitor lithium level Frequency of Lithium monitoring: ONCE A MONTH.5 mEq/L .5 – 1. Lactating. LITHIUM it alters level of neurotransmitters effective if DECREASE HYPERACTIVITY give AFTER MEALS Hx Teachings: diet: High Na (6-10 gms) and High Fluid (3-4L) N Na – 3 gms. (specimen: blood drawn in the morning b4 breakfast or at least 12 hrs after the last dose) NORMAL LITHIUM LEVEL: ACUTE DOSE Below 65 yo Above 65 yo . N fluid intake 3L Basically. wherein there is abnormal discharge of impulse in the brain action : IT INHIBITS the seizure focus and discharge . Kidney disorder . Lithium is a salt - Report the ff s/s (NAVDA) Nausea Anorexia Vomiting Diarrhea Abdl Cramps Report also: FINE HAND TREMORS progressing to COARSE HAND TREMORS. instead of lithium use TEGRETOL.6 – 1.sign of LITHIUM TOXICITY – Dug of choice: MANNITOL DIAMOX Hx Teachings: • • • • Avoid activity that increase perspiration – Na & H2o.2 mEq/L . THIRST and ATAXIC .5 – 1.
WBC and Platelet label CHOLINESTERASE INHIBITORS For MYASTHENIA GRAVIS For ALZEIMER’s DSES : Prostigmin (long acting) and Tensillon : Cognex (tacrine) and Aricept (short acting) Myasthenia Gravis – there is decrease or absence of Acethylcholine (ACTH) ACTH is a neurotransmitter the delivers the order ex. Therefore. good muscle contraction) PROSTIGMIN – long acting – for treatment TENSILLON – short acting – only for 5 mins. Keep at bedside: endotracheal tube – for resp. the drug is given to inhibit cholinesterase in destroying ACTH (so. – it increase muscle strength in 30 seconds (therefore.like valium) MOST DRUGS THAT AFFECT CNS ARE BEST GIVEN AFTER MEALS TOO.effective: if (-) seizure given BEST AFTER MEALS – (except for sedatives. Report s/s of HEPATOXICITY – RUQ pain of abdomen and JAUNDICE Antidote: ATSO4 – it reverses the effect of anticholinesterase • • Check for LIVER FUNX TEST. Brain to muscle to contract/move. Increase chewing ability or able to chew food forcefully) GIVE B4 MEALS or any activity. NSG ALERT: • • • • Check : Report GINGIVITIS. problem ANTICOAGULANT HEPARIN For ACUTE CASES of Manic Case Antidote: PROTAMINE SO4 Given SubQ (Lower Abdl Fat) COUMADIN FOR MAINTENANCE or Chronic CASE Antidote: VIT K Oral LOVENOX Heparin Derivatives Antidote same w/ Heparin . Instruct pt to use SOFT BRISTTLED TOOTHBRUSH. Meds is FOR LIFE. Instruct pt to MASSAGE GUMS and frequent oral hygiene CBC – due to pancytopenia RBC. if dec cholinesterace and inc. if muscle weakness disappear within 30 seconds – it is MYASTHENIA GRAVIS) Drug Action: • • • • Increase muscle strength (ex. Report S/S of Bone Marrow Depression – pancytopenia (dec RBC & WBC). ACTH.
Quinidine (quinam) Side notes: Characteristics of HEART MUSCLE: a. d. Therefore.ability of heart to initiate contraction. diet of patient – no appropriate.ability of the heart to be stimulated Inotropic effect . c. REFRACTORINESS – ability of t heart to respond to stimulus while in the state of contraction.rate of contraction ANTIARRYTHMIC (quinidex. EXCITTABILITY .HOLD “INR” – refers to the upper limit of meds from N value to the maximum dose COAGULATION PROCESS: Vitamin K dependent clotting factors thromboplastin PRO THROMBIN THROMBIN COUMADIN HEPARIN FIBRINOGEN FIBRIN (CLOT) COUMADIN – act as vit k dependent clotting factors HEPARIN – converts PROTHROMBIN to THROMBIN and FIBRINOGEN to FIBRIN . pronestyl) repolarization – resting phase (k goes out) . CONDUCTIVITY – ability to propagate impulses. b. TIL INR of 175). if more than INR .force of contraction or strength of myocardial contraction.Effective if (-) clot Give same time of day Report s/s of bleeding : Hemoptysis Hematemesis Onset: 2-5 days (maintenance case) Check PT (N 11-13 sec and INR 24 sec) HEPARIN: AVOID – green leafy vegetables – bec it is rich in Vit K and will counteract the effect of anti coagulant.RAPID ACTING :onset : 24 – 48 hrs Coumadin and Heparin – NOT to dissolve clot (only as THROMBOLYTIC – meaning it prevents ENLARGEMENT and FORMATION of CLOTS) can be given together ANTIARRYTHIMICS Ex. CHRONOTROPIC Effect . Chromotropic Effect – conduction of impulses. NSG ALERT: monitor PTT (N 60-70 SEC. AUTOMATICITY .
Antiarrythmia is effective if (-) arrhythmia. it affects the repo and depo of heart muscle which causes arrhythmia. to maintain the balance in the Na and K pump give antiarrythmia because it decreases the automaticity of the heart. Health teachings: a.depolarization – stimulating phase (Na goes in) (therefore the depolarization and repolarization of heart muscle depends on Na and K pump. Calcium enters and it will result to a more increase force of contraction due to Na and Ca pump conversion. . if BELOW 70/ min (older child) – HOLD. Give meds anytime. affects the automaticity and excitability of the heart muscle. K – shld be monitored when in this meds therapy (The heart contraction is regulated by Na and K pump. report CNS – confusion. If K decreases. hearing loss and visual disturbances d.) Effects: (+) INOTROPIC – strengthen the force of contraction (-) CHRONOTROPIC – decrease rate of contraction DIGOXIN EFFECTIVE : ACTION it increase FORCE OF CONTRACTION : onset : 5 – 20 mins same DIGITOXIN same 30 mins – 2hrs Give after meals due to GI irritation CLIENT TEACHINGS: Report s/s of TOXICITY : NAVDA Xanthopsia – yellowish vision or greenish halos.110 (infants) – HOLD next dose EXCRETION Digoxin – kidney – monitor renal funx test (BUN & Crea) – report if inc.) K – once it increase or decrease. And so. if BELOW 90. rate and rhythm QUINIDINE PROCAINE LIDOCAINE Ventricular arrythmia For VENTRICULLAR & ATRIAL Fibrillation CARDIAC GLYCOSIDES increase force of contraction. REPORT s/s of QUINIDINE TOXICITY – tinnitus. RASH – therefore SKIN TEST FIRST c.nausea. check pt PR and ECG – waves. Check PR – if BELOW 60/min (adult) – HOLD next dose. ataxia and headache GI . anorexia and vomiting b.
Digitoxin – liver – AST/ ALT DIGIBIND – antidote for digoxin (lanoxin)
a. Digoxin b. Digitoxin
: .5 – 2 ug/L : 14 – 26 ug/L
don’t give if pt taking VIAGRA – it will result to FETAL HYPOTENSION dilatation of coronary arteries and arterioles thereby resulting to DECREASE IN PRELOAD & AFTERLOAD.
Decrease in Preload – decrease in the amount of blood that goes to the LV; AFTERLOAD – amount of resistance offered by blood vessels that heart shld overcome when pumping blood
• • • • • • • •
Effective if NEGATIVE ANGINAL PAIN; Give BEFORE any activity; Administered SUBLINGUALLY (+ burning sensation indicates drug is potent) – NO WATER because it
will dilute the meds;
DOSES: 3 doses at 5mins interval; Report if there is persistence of pain; Check BP and PR; Keep meds in dark container (bec light dec potency); Once the bottle is open, use the meds within 3-6 mos
DO NOT REPORT THE FF: (expected s/s) Hypotension, Headache, facial flushing “why is my face red?”
MUCOLYTICS (an antidote also for ACETAMINOPHEN TOXICITY)
Ex. Mucomyst it decreases the viscosity of secretion; give meds anytime; client teaching: meds can be diluted w/ NSS or cola;
Side effects: NAV + Rashes
if no side effects, repeat dose in 1 hr
BRONCHODILATORS (ex. TERBUTALINE – brethine)
dilates the bronchioles or airways; effective: if (-) bronchospasm; GIVEN in AM to decrease insomnia
REPORT THE FF: insomnia, tachycardia, palpitation-PR, + NAV
Theophylline - N 10-20; - for ACUTE ATTACK and PREVENTION of ASTMA
stimulates productive coughing; effective : (+) COUGHING & SECRETIONS give ANYTIME; sideffects: – NAV + DIZZINESS or drowsiness – avoid activity that required alertness (ex. Driving)
bactericidal; effective: (-) infection; give ON EMPTY STOMACH – B4 MEALS; Hx teachings: REPORT rash, urticaria and “STRIDOR” – indicates airway obstruction; side effects: NAVDA + GI Irritation
I. PENICILLIN : antidote is EPINIPHRINE II. AMINOGLYCOSIDE (gentamycin) effective: (-) infection – give B4 meals; report the ff:
OTOTOXICITY: “I hear ringing in my ear” NEPHROTOXICITY : ”oliguria” NEUROTOXICITY : “seizures”
check BUN, CREA (kidney funx test); check I & O (sign of nephrotoxicity) ANTINEOPLASTIC (adriamycin) for breast and ovarian CA; effective: (-) tumor size; GIVE IN ARM – to prevent HEMMORRHAGIC CYSTITIS Hx Teachings: a. inc oral fluid intake (2-3L/day) – cytotoxic prevention; b. monitor kidney funx – I & O;
THYROID AGENTS (synthroid, cytomel)
for HYPOTHYROIDSM; effective: if Inc in T3 and T4 and NORMAL SLEEP; pt always sleep, therefore give meds in AM – to avoid insomnia; REPORT HE FOLLOWING: insomnia, nervousness; palpitations Take meds LIFETIME (same w/ meds 4 neuro); Check HR, PR and kidney funx test;
(PTU, LUGOL’S SOLUTION)
For GRAVE’S DISEASE or HYPERTHYROIDISM; Effective: Decrease in T3 and T4 (in lab data); Give round the clock; a. Report sore throat, fever, chills, body malaise because meds cause AGRANULOCUYTOSIS; b. Report lethargy, bradycardia, and INCREASE SLEEP – indicates that pt is having HYPERTHYROIDISM; c. Diarrhea with metallic taste – sign of IODINE TOXICITY
effective: N Blood sugar (80-120) for DM Type 1 (insulin dependent); give in AM b4 meals; check: a. instruct S/S OF HYPOGLYCEMIA – dizziness/ drowsiness difficulty in problem solving decrease level of consciouness cold clammy skin b. monitor the blood sugar level in early AM and supper time
INJECT AIR FIRST to NPH then inject air and WITHDRAW FIRST with REGULAR. PEAK OF ACTION (refers to – when patient becomes HYPOGLYCEMIA) REGUALR INSULIN - lunch time Intermediate - late in the afternoon – B4 dinner Long Acting - B4 Breakfast
for DM type 2; stimulate pancreas to produce insulin; effective – N bld sugar level; give b4 meals regularly; teachings: a. s/s of hypoglycemia; b. monitor renal funx test; c. antidote for hypoglycemia – ORANGE JUICE
ALUMINUM HYDROXIDE GEL – antacid and it also dec phosphate level in pt renal failure; Effective: dec phosphate (-) pain give on EMPTY STOMACH (1 hr b4 or 2hrs after meals); instruct pt to REPORT: muscle weakness in lower extremities – indicates HYPOPHOSPATHEMIA administer with glass of water; check phosphate level and renal funx test; assess for constipation
c.effetctive: incrase urine output. Tubules LOOP DIURETICS (lasix) . c. urine output. report muscle weakness. meds is given in short duration only because of dependency teachings: a. give AFTER MEALS –for dyspepsia. s/e: diarrhea. PR and BP K-SPARRING (triamterene. orange THIAZIDE (diuril) give in AM. Causes hypokalemia – therefore check electrolytes Increase fld intake – to avoid dehydration DIURETICS Target Organs a. K level. aldactone) effective: inc. monitor for hypokalemia level and I & O. give in AM. give K rich food – banana.bulk forming . be near or stay near CR. b. monitor for hypokalemia. Diamox – exerts effect at Proximal Convuluted Tubules. Diuril – at Distant Con. c.LAXATIVES (dulcolax) Colace Metamucil Dulcolax Lactulose – stool softener . check I & O. NO lactulose for pt w/ diarrhea. .rapid acting .15-30 mins effective : (+) BM. d. teachings: monitor for HYPERKALEMIA check PR and K ANTIGOUT . b. . b.teachings: a. e. Lasix – at Loop of Henle. give AT HS (if NOT diagnostic procedure).give in morning to prevent nocturia.
Give ANYTIME – but for LIFETIME.PROBENECID COLCHICINE ALLOPURINOL . MgSO4) relax the uterus.promotes excretion of uric acid . blurred vision d. teachings: may cause blurring of vision lower conjuctival sac CARBONIC ANHYDRASE INHIBITORS (diamox) for GALAUCOMA – lifetime. it causes blurring of vision and brow pain.s/effects: NAV + .dizziness/drowsiness Hypersensitivity agranulocytosis (check CBC) .for ACUTE GOUT . report: s/s of dehydration bec of diuretic effect c.ONSET: 1-3 wks TEACHINGS: a.acid of u. check urine output. check if pt has skin irritation – may burn the skin TOCOLYTICS (Yutopar.prevents or dec formation preventing deposition of u. Teachings: a.URICOSURIC . press the inner canthus for 1-2 mins to prevent systemic side effects (hyperglycemia and hypotension) MYDRIATRIC - (AK-Dilate) effective: pupillary dilatation. given in AM to prevent insomnia.ONSET: 8-12 wks .has anti-inflammatory effect by . acid @ joints . b. Monitor uric acid levels. c.NAV + Bldg and Bruising . b. . retin-a) decrease sebaceous gland size. effective: (-) pre-term or relaxed uterus. monitor I & O and IOP ANTI-ACNE (acutane.therefore check if pt is pregnant. b. to decrease production of acqueous humor. administer meds at lower conjunctival sac. avoid sunlight: photosensitivity pregnancy: fetotoxic . drug of choice for pre-term labor. give b4). give ANYTIME (but if pt for surgery. Increase ORAL FLUID INTAKE. MIOTICS (timoptic. piloca) DECREASE IOP (N12-21) for pt w/ glaucoma. effective to pt with MENIERE’S DSES – dec vertigo teachings: a.for CHRONIC GOUT . effective: N IOP and Inc. urine output.
check patellar reflex – shld be (+) knee jerk HOLD if RR – 10/min and urine output: 15ml/hr Antidote: Calcium Gluconate OXYTOXIC PITOCIN METHERGIN To induce labor To prevent post partum hemorrhage Effective: Firm and Contracted Uterus Give anytime If IV. Hypertension (cardiovascular effect of the drug) d.- give: ORAL – B4 meals and IV – anytime. signs of Ca Intoxication: hypotension. Duration and Frequency of Uterine Contraction PROSTAGLANDIN (cytotec. Check BP. decrease ripening of the cervix w/c leads to effacement then dilatation then abortion. check bld pressure. b. check RR – at least 12/min d. check for pregnancy bec it may cause abortion . hypothermia and hypocalcemia b. use “piggy back” Teachings: a. E2gel) anti ulcer drug to dec gastric acidity.report if beyond 90 sec – sign of uterine hypertonicity e. urine output (N 30ml/hr) c. teachings: a. Uterine Contraction – especially the duration – N 30-90 sec . assess for diarrhea and gastric irritation. Headache c. Check Force. give after meals. REPORT the ff: HYPOTENSION (due to inactivation of ANS – neurological effect of drug).
TIPS ON PHARMACOLOGY
Patient receiving DIAZEPAM, the nurse notice that there is no change in patient behavior. What shld the nurse do? – VERIFY THE PT DIET COGNEX – given with AZEIMERS’S DSES – to increase mental functioning Pt w/ PVC : bedside : XYLOCAINE Pt w/ COMPLETE HEART BLOCK: give ATSO4 – it increases HR Pt w/ DIVERTICULITIS (pt has diarrhea) – the ff meds were given: what meds the nurse shld question : LACTULOSE Morphine S04 given to pt with Pul. Edema – to decrease anxiety Pt ask the nurse on why she will take COUMADIN when shes already taking HEPARIN – Heparin is given for ACUTE CASES while Coumadin for maintenance Pt on CHEMOTHERAPY complains of nausea and vomiting, w/c meds can be given – ZOFRAN Expected side effects of STEROIDS : wt gain, obesity and Inc appetite Pt is taking LEVODOPA – observe for URINARY RETENTION ADREAMYCIN – causes hemorrhagic cystitis DESMOPRESSIN ACETATE – administered INTRANASALLY FESO4 – shld be given w/ orange juice ASPIRIN I s given to pt w/ TIA – to decrease platelet aggregation Pt taking ANCEF – observe for skin rashes Pt to receive NPH at 7:30am, the nurse shld expect for hypoglycemia – LATE in the AFTERNOON
TYPES OF PRECAUTION
DIARRHEA HEPA B C MRSA
(enteric) x x
x yes yes
yes yes yes
yes yes yes
x yes yes
MENINGITIS/SEPTIC SCABIES TB
P – private room H – handwashing GL - gloves GW – gown M - mask
AIDS – universal Norwalk Virus – respiratory Hepa A – contact MRSA – contact Scabies – contact
Day 6 (Feb 9, 05)
Priority: Oxygenation The disorders result as alteration in the function of HEART (pump), BLOOD (transport mechanism of oxygen, nutrients, hormones & CO2) and BLOOD VESSELS (passageway).
a. all factors necessary for appropriate cardiovascular functioning are present at birth EXCEPT VIT. K (w/c is produced by intestinal mucosa); b. there are structures which are present at birth that may alter the route of blood circulation (present at birth: foramen ovale, ductus arteriosus, ductus venosus) c. note the CARDIAC RATE of pediatric pt
(minimum $ y. children – 90-110, older c. – 70)
REPORTABLE S/S FOR ADULT
• • Palpitation, Pain and Paroxysmal Nocturnal Dyspnea For pediatric patient: observe for PALLOR – if (+) indicates ANEMIA for baby Nocturnal dyspnea – diff. of breathing at night Paroxysmal ND – when pt feels as if he’s drowning
S1 - normal – “lubb” S2 - -do- “dub”
in assessing S1 & S2 use BELL of steth
(ABNORMAL for adult pt – it indicates CHF or Aortic Stenosis)
S3 - N for Pediatric pt
Steth - BELL – for LOW PITCH SOUND (ex. Murmur) Diaphragm – for HIGH PITCH SOUND
Renal Failure) Kidney – produce erythropoiten that stimulates bone marrow to produce RBC TYPES: a. burn) ANAPHYLACTIC . Bld Trans – for jehova’s use plasma expander) ANEMIA MP: Decrease RBC due to decrease production or increase destruction Risk Factors: Age Gender Surgery Secondary to existing medical condition (ex. d. Mitral Valve Dses) HYPOVOLEMIC . poison) NEUROGENIC . e. asthma.cause by allergic reaction (laB procedure w/ dye. Iron Deficiency Anemia (IDA) Pernicious Anemia (PA) Folic Acid Deficiency Anemia (FADA) Sickle Cell Anemia (SCA) Aplastic/ Fanconis Anemia (AA) Talasemia Anemia (TA) .check CVP Nsg Dx: FLD VOLUME DEFICIT rel to dec in Circ Vol. Hypotension. f. Septicemia) TRIAD SYMPTOMS OF SHOCK a. Patient in shock. Altered level of consciousness b. c.related to fluid loss (pt w/ open wound.caused by vasomotor collapse (vasomotor – located @ medulla oblongata w/c is responsible for dilatation & constriction of bld vessels) SEPTIC – due to systemic infection (ex.there is also (+) pallor and (+) oliguria – due to dec bld circulation & narrowing of bld vessels Lab Data (to check bld volume circulation) – check HEMATOCRIT (N-35-45%) . traumatic injury. NSS. MI. Priority Intervention: Fld replacement (D5Lr. Atherosclerosis Heart Dses. Tachycardia and Tachypnea (dec bld circulation – result to dec o2 in the brain). b.SHOCK mp: decrease in circulating blood volume TYPES CARDIOGENIC – pump failure (CHF. c.check Urine Output .
Correct the deficiency – by administering iron supplements. there is that GASTRIC ATROPHY w/c leads to dec in the Intrinsic factor S/S: 3F (fatigue. provide patient with BED REST – due to fatigue PERNICIOUS ANEMIA common in elderly. cold clammy skin Dyspnea (due to dec RBC) Lab data: Decrease in HgB (N male: 14-18. “egg yolk” – iron. dried foods. characteristic of patient: chubby but pale they are also called “milk babies” those baby 5 yo but still taking milk (milk are poor source of iron) MP: Nutritional Deficiency S/S : Fatigue Fainting Forgetfulness Pallor. Oral FeSO4 (take w/ orange juice) if ELIXIR – use straw to avoid staining of teeth if IM (inferon) – “Z” track method (for Z track IM – PULL SKIN LATERALLY. . c.IRON RDA – 15-30 mgs/ day eg. forgetfulness) Beefy Red Tongue or glossitis Peripheral Neuropathy (tingling sensation at lower extremities – usually both legs are affected) . wait 10 seconds before pulling the needle) FeSO4 – evaluate AFTER 4 weeks to check the effect b. common in POST GATRIC SURGERY (intrinsic factor – the one that absorb vit b12) Main Problem: Lack of INTRINSIC FACTOR at the stomach In elderly. deep IM. “egg white” – CHON). Diet: iron rich food – (organ meat. Female: 12-16) Characteristic of RBC: HYPOCHROMIC & MICROCYTIC Nsg Dx: Activity Intolerance Priority Intervention: a.IRON DEFICIENCY ANEMIA common in infants and children. fainting.
SCHILLING’S TEST (24hr urine) c.Lab Data: a. check Hgb b. lactating and overcooked food. 1 DSES BOTH parents w/ Disease Risk Factors: Dehydration (dec in circ bld volume – result in sickling of RBC). NEUROPATHY Lab Data: HgB Folic Acid level (N 4mg/day) – green leafy veg. (spinach) Nsg Dx: Activity Intolerance PI: (NO RISK FOR INJURY coz NO P. Bed Rest SICKLE CELL ANEMIA autosomal recessive hereditary presence of “S or C” shape Hgb due to dec O2 N TRAIT TRANS 50% 25% 0 0 0 50% 50% 50% 100% (SICKLING OF RBC) STATUS DSES TRANS 0 25% 50% 1 PARENT W/ TRAIT BOTH PARENTS w/ TRAIT I parent TRAIT. folic acid in the diet – g. FOLIC ACID DEFICIENCY ANEMIA common in infants. Once a month for lifetime). RBC characteristic : MACROCYTIC & HYPERCHROMIC Nsg Dx: Activity Intolerance Risk for Injury due to p. Infections Conditions that lead to SHOCK S/S: 3Fs + Fever (due to dehydration) + Pain + Jaundice Hepatomegally . NEUROPATHY) Inc. Bed rest – due to fatigue (IM. Main Problem: Deficiency in Folic Acid or VIT B9 or FOLACIN S/S: all symptoms of pernicious anemia EXCEPT P. adolescents. Correct the deficiency – give Vit B12 b. neuropathy Priority Intervention: a. leafy. pregnant.
Aplastic/ Megaloblastic Crisis – – massive entrapment of red cells in the spleen & liver bone marrow depression w/c resulted to DEC RBC. Greeks. Genetic Counseling. Italian. Spleenic Sequestration Crisis c. Vasocclusive Crisis (hallmark of the dses) . Bleeding & Clotting time Nsg Dx: PI: Activity Intolerance (dec in RBC) Risk for Injury (dec in WBC and Platelet) Bld transfusion. acetaminophen Since HEREDITARY – refer to geniticist APLASTIC ANEMIA MP: Hereditary (there is DECREASE IN RBC. Clotting Factors Platelet.Complications: a. Bed rest THALASEMIA Risk Factors: Common in Blacks.bld vessels obstruction by rigid and tangled cells w/c causes tissue anoxia and possible necrosis b. Minor Thalasemia Anemia – mild anemia: 3Fs . WBC & PLATELET Lab Data: Sickledex Test (+) Turbid Solution Nsg Dx: Activity Intolerance Fld Volume Deficit Pain – due to vasocclusive crisis PI: Hydration and relief of pain (inc oral fld intake) Prevent dehydration Meds for Pain – Morphine SO4. Indians MP: Hereditary Autosomal Dominant – common in female and male There is a defect in polypeptide Chain of HgB – ALPA and ETA Chain – there is RBC destruction Types: a. WBC & PLATELET) Autosomal Recessive S/S: 3Fs + Pallor + Dyspnea Risk for Infection (dec in RBC) Bleeding (dec in Platelet) Lab Data: HgB. Chinese. CBC. Reverse Isolation.
cause: idiopathic . Major TA – severe anemia + Spleenomegally Lab Data: HgB Clotting and Bleeding Time Nsg Dx: PI : Activity Intolerance Risk for Injury Bld Transfusion. MYELOGENOUS – adolescent and adult (proliferation of granulocytes) TRAID S/S: • • • Anemia (initial) + 3Fs Bleeding Infection Lab Data: WBC – hyperleukocytosis (150 – 500. IVF Dietary supplements of Folic Acid and Iron Surgery (last resort) LEUKEMIA MP: proliferation of immature WBC Characterized by Remission and Exacerbation Types: a.b. LYMPHOCYTIC – common in young children (proliferation of lymphocytes) b.000K) – expected NDx: Risk for Injury Activity Intolerance Risk for infection Bed rest Avoid Contact Sports Reverse Isolation Blood transfusion Bone marrow transplant PI: IDIOPATHIC THROMBOCYTOPENIC PURPURA (ITP) or WERLHOF’S DSES common in BLACKS. Intermedia TA – more severe anemia + Speenomegally Jaundice (inc deposition of iron @ tissue) Hemosidorosis c.
HRate from 84 to 122 bpm.000 – 450.Inc. Hemo. IVF and Bld Transfusion Corticosteroids – “wonder drugs” HEMOPHILIA inherited – bldg disorder TYPES: a. A .deficiency in Factor 9 c. Deficit PI : (due to bldg) SAFETY –prevent bleeding Give pt platelet. IMMOBILIZE.Autosomal Recessive Link (from mother to male) Von W Dses . (above mentioned are signs of HEMORRHAGE) Lab Data : PROLONGED CLOTTING TIME Nsg Dx : Risk for Injury PI : SAFETY then RICE (REST. w/c one is MOST SUGGESTIVE of CARDIOGENIC SHOCK . Hemo.unknown (viral and autoimmune) s/s: petechiae ecchymosis hemorrhage (all signs of bleeding) (spontaneous bldg) lab data: Platelet Count of less than 20. COLD COMPRESS. knee and elbow joints. ELEVATE) For JEHOVAH’S – use plasma expander (cryoprecipitate) instead TIPS FOR BLOOD DISORDERS If all of the ff data were obtained by the nurse.Autosomal Dominant – Mother and Father S/S: Hemarthrosis – Hematoma Hematuria Hematemesis bldg between joints that usually affects ankle. Von Willebrand’s Dses – common in male and female HEMPPHILIA A and B .000 (N 150. .deficiency in factor 8 b. B .000) Nsg Dx: Risk for Injury Fld Vol.
MANIFESTATION – HEMARTHROSIS. w/c of the ff is EXPECTED pt w/ IDA has NSG DX of ALTERED NUTRITION LESS THAN BODY REQUIREMENTS.INCLUDE VEGS. w/c of the ff shld the nurse instruct the pt to do . w/c of the ff is TYPICAL for patient w/ ANEMIA . a mother of 15 mos old child with IDA makes the ff comment. a 7 yo boy with HEMOPHILIA was admitted. The nurse admitted a 4 yo child with SICKLE CELL DSES – the priority for the patient is – HYDRATION. w/c of the ff is indicative of thrombocytopenia . common manifestation of LYMPHOCYTIC LEUKEMIA is – PETECHIAE. w/c of the ff is the priority intervention for pt w/ IDA – PROVIDE BED REST ALTERNATING w/ activities.SHORTNESS OF BREATH ON EXERTION.“MY CHILD DRINKS 2 QUARTS OF MILK/DAY”. w/c one is related to child condition . AND MEAT in your diet at least 1 meal a day.HEMATURIA CARDIOVASCULAR PEDIATRICS FETAL CIRCULATION 3 FETAL STRUCTRUES .
closes at birth) LA R Ventricle L VENTRICLE LUNGS LV L ATRIUM P. ARTERY DUCTUS ARTERIOSUS (functionally closes by 3-4 days at birth) AORTA Therefore. closes at birth) LIVER UMBILICAL ARTERIES Vena Cava Right Atrium AORTA FORAMEN OVALE (functionally. CONGENITAL HEART DISEASE CONGENITAL HEART DISEASE ACYANOTIC HEART DSES CYANOTIC HEART DISEASE Dec Pulmonary Bld flow Obstructive CHD Decrease Pulmonary . if these 3 fetal structures will not close.PLACENTA UMBILICAL VEIN DUCTUS VENUSUS (functionally.
Vent. Septal Defect (most common) Atrial Septal Defect Patent Ductus Arteriosus Pulmonary Stenosis Aortic Stenosis Coarctation of the Aorta Tetralogy of Fallot (most common) Transposition of the Great Vein Truncus Arteriosus Tricuspid Atresia Usually due to: Maternal Infection – measles. pox Age 40 and above Medical Conditions – DM Alcoholism Signs and Symptoms: Difficulty feeding Retarded Growth Tachypnea/Tachycardia Frequent URTI ANS – brow seating (check for “murmur”) Complication: CH Failure Lab Data: 2 D Echo CVA (due to plycythemia – Inc RBC) Nsg Dx: Altered Tissue Perfusion PI : Oxygenation Surgery If < 2yrs old prepare the patient the moment the diagnosis was confirmed/ determined. therefore prepare the child 3 days prior to surgery) If > 7yo – parents decision PATENT DUCTUS ARTERIOSUS connection problem : P Artery and Aorta “machinery-like murmur” (+) brow seating (+) retarded growth (+) tachycardia/ tachypnea LAB DATA : 2 D-Echo CVP . c. For 2-7 yrs old – surgery is equal to child age ( ex 3yo.
especially to JAPANESE children and toddler 5yo and below S/S : High Spiking Fever for 5 Days Lymphadenopathy Strawberry Tongue Palmar and Feet Desquamation . Lab Data : BP. right vent. : SQUATTING Surgery COARCTATION OF AORTA Higher BP in the Upper Extremities and Lower BP in the Lower Ext.PExam Nsg Dx : Altered Tissue Perfusion PI : Oxygenation INDOMETHACIN ACYANOTIC POSITION: ORTHOPNEIC (position for CHF) then SURGERY TETRALOGY OF FALLOT pulmonary stenosis. coarctation of aorta. vent septal defect “boot-shape heart” tet spell – squatting w/ cyanosis LAB DATA : 2 D-echo Complication : CVA – check for RBC Count Nsg Dx : Risk for Injury PI : Oxygenation Position the Pt. Hypertrophy. 2 D-Echo PI : Oxygenation Position the patient: Orthopneic or semi – fowler’s position KAWASAKI’S DISEASE due to acute vasculitis (inflammation of bld vessels) of the heart.
of SCAR FORMATION that can lead to MI). w/c intervention is priority – decreasing the metabolic demand of the heart CORONARY ARTERY DISEASE (CAD) Main Problem : NARROWING and OBSTRUCTION of Coronary Arteries which could lead to HYPOXIA – reversible (which could further progress to ANGINA) and or ISCHEMIA – irreversible (that could progress also to dev’t.Lab Data : Nsg Dx : No Specific Diagnostic test Check ECG Altered Tissue Perfusion Altered Thermoregulation Altered Skin Integrity High CHON Diet : TIPS FOR CARDIOVASCULAR – PEDIA w/ of the ff is an OUTSTANDING SYMPTOM OF CARDIOVASCULAR PROBLEM in children – difficulty in feeding. w/c of the ff is an appropriate intervention for a child who keeps on squatting because of Tetralogy of Fallot . Risk Factors: Family History Atherosclerosis Smoking Elevated Cholesterol HPN . the BLD VESSELS INVOLVE in PATENT DUCTUS ARTERIOSUS – pulmonary artery and aorta.if LESS THAN 1 yo – flex lower extremities towards the abodomen. when admitting a pt w/ suspected congenital heart disease. a child who was brought in to a well baby clinic turns cyanotic while crying – REFER to the physician. w/c of the ff data in mother health history indicates a risk factor for congenital heart disease – ADVANCE AGE.
L arm. SAME • ECG – initial change is ST SEGMENT DEPRESSION w/ . excruxiating Pain radiates to the L Jaw.Obesity Physical Inactivity Stress CAD HYPOXIA ISCHEMIA NECROSIS ANGINA Myocardial Infarction – “ jaw pain” this leads to decrease O2 – and will result to the conversion of aerobic metabolism to anerobic thereby resulting to the production of LACTIC ACID – that will stimulate the nerve ending of the heart w/ will produce/ result to PAIN that is precipitated by: EATING Elimination – due to valsalva manuever Exercise/effort/ exertion Emotion Extreme Temperature – “cool temp” – vasoconstriction sEx PAIN MTOCARDIAL INFACRTION • • • • • ANGINA Pain confined at sternal area Pain that resembles “pressure” Relieved by rest & NITROGLYCERIN SAME Precipitated by 6E’s Pain that resembles “indigestion”. crushing. L shoulder Relieved by SO4 Opiods (MORPHINE) Pain occurs AFTER MEAL (post cebum) or AFTER ACTIVITY • S/S of above mentioned + SHOCK s/s – esp to CARDIOGENIC SHOCK w/c is due to PUMP Failure – that leads to dec cardiac Output that leads further to CHF.
Decubitus Angina – when pt is lying down Intractable Angina – unresponsive to tx Post MI Angina For patient with MI – focus on complications : . Unpredictable – relieved by Nitroglycerin. Nocturnal Angina – occurs at night. sublingual provide rest – due to pain b.administer O2 as ordered . Variant/ Prinzmetal – severe form of Angina. ANTIDOTE : Naloxone HCL – Narcan ANGINA : Nitroglycerine – dark container give b4 activity maximum of 3 doses. 5 mins interval effective: tingling sensation.T WAVE INVERSION Increase CHOLESTEROL SAME HDL – “good” or Healthy – liver for metabolism – 30-80 LDL . Diet : Low Na and Low Cholesterol HEALTH TEACHINGS: Identify types of Angina: Stable Angina – predictable – angina that occurs w/ activity.position : SEMI-FOWLER’S .“bad” – peripheral vascular system – bld vessels.60-80 CARDIAC ENZYMES #1 Myoglobin Troponin CK – within 2-3 days LDH 1&2 – within 10-14 days SAME • Nsg Dx : PAIN Altered Tissue Perfusion Impaired Gas Exchange • Priority : Airway (Oxygenation) • Goal of CARE a. To decrease oxygen metabolic demand .administer meds: MI : Morphine SO4 – monitor RR. effective : (-) pain.
synchronize .Arrythmias .Inc HR (tachycardia) – that will result to enlargement of the heart muscle (hypertrophy) – w/c can lead to dilatation and congestion of the cardiac muscles . DIET : avoid PROCESSED FOODS.esp. Right Heart Failure – will be the late signs of CHF as complication of LHF Risk Factors to Heart Failure: . Ventricullar Fibrillation – Lidocaine – s/e “rashes” CARDIOVERSION .take meds b4 sex. for VTACH w/ PULSE DEFIBRILLATION .for VTACH w/o PULSE SEX – for pt w/ MI – resume if pt tolerate 2-3 plights of stair w/o pain.position during sex : passive – let the girl do her share ACTIVITY – advised pt to have frequent rest period.a. Weak or absent PULSE – indicative of VENTRICULLAR FIBRILLATION Report NECK VEIN DISTENTION – indicative of CHF complication Report BLEEDINGs – especially to pt on THROMBOLYTICS – t-PA and Streptokinase CONGESTIVE HEART FAILURE main problem : PUMP FAILURE – inability of the heart to pump an adequate amount of blood to meet the metabolic demands of the body how will the heart compensate? The HEART will pump harder. PUMP FAILURE EFFECTS: Backward Effects : backflow of blood – systemic congestion. PVC or PVBeats – defibrillation/ cardioversion b.Renal Failure LEFT SIDED HF – dyspnea and other “pulmonary s/s” – “crackles” .Coronary Dses & HPN . . . yellow cake FOR ANGINA APIN – instruct patient to report pain that last more than 2o minutes (indicative of MI). Forward Effects : decrease cardiac output – dec in tissue O2 perfusion – that leads to overwork respiratory system LEFT HEART FAILURE – early signs of CHF Therefore.thereby resulting to decrease in the cardiac output.unsynchronized . MILK Salty Sea Foods Pastries – esp.
INC. HYPERTENSION MP : blood pressure higher than 140/90 (hypertensive state) pre hypertensive phase PREGNANCY INDUCED HPN Elevation of BP that occurs after 20-24 (5 mos. Obesity Stress Smoking a. therefore N BP : 110/70 Risk Factors: if BP elevated B4 20-24 wks & cont after delivery – CHRONIC HPN Levels of PIH Common in BLACKS. report s/s of complications DIGITALIS – D. Toxicity: yellow vision.age of viability) wks of gestation 120/80. HYPERTENSIVE DISORDER OF PREGNANCY . Activity – rest b. PRIORITY : DIET : LOW Na – NO PMS HEALTH TEACHINGS : a. PRE-ECLAMPSIA S/S + convulsion.ECLAMPSIA TYPES: .RIGHT SIDED HF – systemic effect – distended jugular vein Ankle edema Ascites Hepatomegally LEFTS SIDED HF Lab Data : Swan Ganz PAP (N 20-30) PCWP (N 8-13) X-ray Nsg Dx : RIGHT SIDED HF CVP (N R – 0-12. BP + EDEMA & Proteinuria (s/s of PRE-ECLAMPSIA) b. V Cava – 5-12) X-ray Altered Tissue Perfusion Ineffective Breathing Pattern – for LHF Fld Volume Excess – for RHF Oxygenation Position: Semi-Fowler’s Administer: Digoxin – absorb in GI Vasodilators Diuretics Morphine – for CHF – it causes pheriperal vasodilation by Decreasing the amount blood going back to the heart. dietary counseling – NO PMS c. Muscle weakness (hypokalemia) – that can lead to arrythmia Dyspnea – s/s of pulmonary edema. ECLAMPSIA + Bleeding = HELP SYNDROME . Abdl pain & Headache PHASE c.
ECLAMPSIA + BLEEDING = HELP SYNDROME H – emolysis E – levated Liver Enzyme L – ow P..simvastatin & lovastatin – give after meal nighttime Monitor liver Funx test – meds above are hepatotoxic . c. onset is CHRONIC MALIGNANT – acute or abrupt onset. PROTENURIA is >5mg/hr HEADACHE and ABDOMINAL PAIN – s/s of ECLAMPSIA. indicative of impending convulsion. PHARMACOLOGIC MEASURES Antihypertensive Diuretics Aspirin Antilipimic . Non-Pharmacologic Features Stress Management Deep breathing Diet : Low Na/ Cholesterol Position : if inc BP – supine position II. b. d. MILD b. PROTENURIA is <5mg/hr (N . short in duration SECONDARY – related to existing medical condition HPN IN PREGNANCY – usually related to generalized spasm of the arteries PRE-ECLAMPSIA TYPES: a.a.5-1GM) BP 160/90. Inc BP and Inc Cholesterol LAB DATA: Nsg Dx: Altered Health Maintenance Risk for Injury PIORITY: How? Stabilize BP I. SEVERE BP 140/90. ESSENTIAL HPN – cause – unknown BENIGN – usually of long duration.latelet (All are signs of bleeding) S/S of HPN: - Headache Retinal Hemorrhage Edema above s/s can further lead to complications: Coronary artery dses CHF Chronic Renal Failure CVA Blood Pressure Elevated Cholesterol For PIH : (+) Proteinuria.
Pts w/ PIH meds: a. Darkened room – to dec stimulus thereby preventing convulsion PERIPHERAL VASCULAR DISEASE Arterial Obstruction Color pallor Edema (-) or mild Nails brittle nails Pain intermittent claudication Pulse (-) Temperature cold Ulcer dry & necrotic TYPES: BURGER’S DSES (THROMBO ANGITIS OBLITERANS) common : MALE FEMALE MALE Venous Obstruction ruddy (+) & severe N homan’s sign (+) warm wet (pain @ gastrocnemeus area) RAYNAUDS ARTERIOSCLEROSIS OBLITERANS . MgSo4 – antidote is CAgluconate b.
.AREA AFFECTED : Lower Ext. accompanied by color changes: PALLOR that progresses to CYANOSIS then REDNESS & aggravated by exposure to cold – NO SHOVELING OF SNOW & COLD BATH & exposure to cold – wear gloves S/S: Outstanding s/s is INTERMITTENT CLAUDICATION – pain that worsens w/ activity or pain that is relieved by rest.(+) pain that narrowing of blood vessels.lower ext Arteries ONLY Upper & Lower Ext Affects arteries and veins Arteries ONLY MP : “Angitis” – inflam. DOPPLER USG Nsg Dx : PAIN Altered Tissue Perfusion . elevate/ raise the legs then stand up and observe for bulging of vein. conservative test – TRENDELENBURG TEST – pt lie down. CLOT + Inflammation job related (prolong sitting/standing) pregnancy hereditary secondary to existing medical condition s/s : dilated tortous vein dragging sensation “heaviness” edema (unilateral/ bilateral) – tape measure to monitor leg circumference Pain Lab data: 1.(+) pain usually related to . 2. Upper Ext – 97% 3% .aggravated by smoking – causes further narrowing of bld vessels WBC & ESR DOPPLER USG Inc Cholesterol and Ca LAB DATA : Inc Nsg Dx: Altered Tissue Perfusion same Pain -do- same -do- PI : MEDS : Relief of Pain (for all types) -do- -do- Anticoagulants Vasodilators (papaverin – pavabid) Antihypertensive DIET : Low Cholesterol VARICOSE VEIN THROBOPHLEBITIS PHLEBOTHROMBOSIS Clot weakening of venous valves. of Spasm of Arteries Arteries & veins of lower ext of Upper & lower ACUTE Hardening of arteries due to fatty deposits INTERMITTENT CHRONIC .
Prepare pt for Surgery of tunica adventitia to bulge CARDIO-PULMONARY RESUSCITATION (CPR) indicated for cardiac arrest when pt is BREATHLESS and PULSELESS. there will be 80 compression and 15 – 20 rescue breaths Depth of Compression : 11/2” – 2” If too deep .weakening of portion of abdl aorta – leading to dilation. KNEE HIGH STOCKINGS. COLD COMPRESS ABDOMINAL AORTIC ANEURYSM (AAA) . shake the pt – are you ok? If breathless & pulseless then. #2 skin color TIPS FOR CARDIOVASCULAR – ADULT .Hx Teachings : • • • Elevate the legs above the heart. Surgery – vein ligation & stripping Sclero therapy – injection of sclerosing agents to make wall stronger thereby preventing veins to bulge. • • • NO MASSAGE – coz it may dislodge the clots. ACTIVATE the EMS – Help! CPR (1 or 2 rescuer : 15 : 2) In 1 minute.could be related to aging and HPN TYPES: Fusiform .part of inner intima and media was dissected w/c lead to the pushing Saccular S/S: Pulsating Abdl Mass Low Back Pain Higher BP in Upper Extremities If RUPTURE occurs – could lead to SHOCK LAB DATA : PRIORITY : Altered Tissue Perfusion Risk for Injury NO ABDOMINAL PALPATION bec it may lead to rupture – PLACE WARNING AT THE DOOR OF THE PT.it may fx the liver Effect of CPR : #1 (+) Pulse. .entire wall is affected Dissecting . Use support stockings.
w/c of the ff data supports the Dx. use steth directly on pt. A pt with R sided HF will manifest – distended jugular vein RESPIRATORY General Consideration: use the DIAPHRAGM of the steth when assessing breath sounds.#1 or Early sign for respiratory distress. Note for chest indrawing (if +. Tachycardia . A pt has R sided CHF. Ff MI. A nurse is assessing a pt w/ MI – w/c of the ff is the characteristic of PAIN – pain radiates to the jaw. may indicate Pneumonia) and rapid breathing Reportable Signs and Symptoms : common TO ALL RESPIRATORY DISORDERS “RE TACHY TACHY D C” RETRACTIONS . disorientation. In addition to assessing a pt w/ Burger’s Dses.relaxation and stress mgt.• • • • • • • • • • • A nurse is assigned to a pt with arterial dses of lower extremities. when shall I resume sexual activity? – when you can climb 2 plights of stairs w/o shortness of breath then sexual activity is safe. w/c of the ff is expected – hepatomegally. visual disorders & hallucination – the nurse best action is to – CALL THE PHYSICIAN. Apt w/ CHF who is taking diuretics exhibits the ff. when the pt chest is hairy. Pt exhibits intermittent claudication – another sign of peripheral dses is w/c of the ff – tropic skin changes. A pt was diagnosed w/ MI develop atrial fibrillation – this may possibly lead to – CEREBRAL EMBOLISM. In utilizing mind over body principle for pt w/ HPN – w/c intervention is appropriate . wet the hair w/ dump cloth – because dry hair interfere w/ auscultation Consideration w/ Pediatric Patient: when assessing pediatric pt. RR is affected when – therefore check RR FIRST. w/c of the ff is expected – calf pain after short walking (intermittent claudication). – smoking. w/c requires further investigation (not expected to pt) – wt gain of 3 lbs in 2 days. skin – because clothing my interfere w/ auscultation. A pt w/ CHF was admitted exhibiting confusion.
Distress Syndrome – a group of symptoms (mgt: maintain temperature). the child can maintain temperature by burning brown fat – and increase burning – bi products is Increase fatty acids that will cause acidosis – that can worsen the Resp. c.note for abnormalities in RATE. Apneustic – forceful inspiration followed by slow expiration – dying patient At birth. co2 then combine with H2O to form carbonic acid – if inc. HYPOVENTILATION Cause: Lack of O2 Effect: ACIDOSIS HYPERVENTILATION ALKALOSIS Cause : lack of CO2 – the pt will decrease rate of breathing to save CO2. b. TACHYCARDIA and Cyanosis a. RHYTHM & DEPTH Common CHARACTERISTIC in Breathing BIOTS – increase in depth followed by apnea. . Pre-Term. Tachypnea Dyspnea Cyanosis – late sign of respiratory Distress Key Points for Assessment . can lead to acidosis – and the brain will compensate by hyperventilating – and increase elimination of CO2 will cause ALKALOSIS.pt w/ neuro impairement Cheyne-Stroke – increase in rate and depth of breathing followed by apnea. Those w/ episodes of Apparent Life Threatening Events Siblings of those who died w/ SIDS (usually 2-3 sis/ bro – died) Hypoventilation Dx Procedures: Cardioneumogram – measures O2 Polysonography ABG Analysis Tx : • • • Administer Theophylline (N 10-20 mg/ml) S/Effects: NAV and Insomia Caffeine Assist mother threu grieving process (esp to Apnea of Infancy) Hx Teaching : Teach parents CPR .nero case Kussmauls – deep rapid breathing. APNEA OF INFANCY Occurs in Full Term Baby (37wks onwards) SIDS/ CRIB DEATH Usually occurs in Pre-term Risk Factors: s/s : episodes of APNEA. . d.
trumpet CYSTIC FIBROSIS multi system dses (GI and Respiratory System) characterized by excessive mucus production by exocrine glands. ABDL DISTENTION Malabsorption Syndrome – STEATORRHEA – foul-smelling stool w/ Inc Fats & Bulky Salty to Kiss – bec skin becomes impermeable to Na . AVOID PROPANOLOL and ASPIRIN – causes BRONCHOSPASM. Risk Factors : Environmental factors Emotion Effort/ Exercise S/S : WHEEZING sound – due to obstruction Orthopnea Whitish Sputum Pulmonary Funx test Incentive Spirometer Ineffective airway Clearance AIRWAY Lab Data : Nsg Dx : PI : Intervention : Bronchodilators – theophylline Rest Oxygen – low flow (1-2 l/min) – higher than this will result to decrease in the stimulus for breathing – w/c is CO2 Nebulization Chest Physiotherapy – b4 meals or at bed time High Fowlers Intermittent Positive Pressure Breathing Aerosol Liberal Fluid Intake Meds : Aminophylline Steroids Theophylline Histamine Antagonist Mucolytic Antibiotics Hx Teachings : Appropriate rest. Exercise – “blowing exercises” – bubbles. GI Autosomal Recessive TRAIT TRANSMISSION – 50% Chance for DISEASE TRANSMISSION – 25% Respiratory Hereditary For each pregnancy S/S : MECONIUM ILEUS – within the 1st 24-36 hrs – if baby fail to defecate – suspect for CF.ASTHMA MP : Inflammation of bronchioles that leads to excessive mucus production that resulted to narrowing and obstruction. Activity – avoid those that will expose pt to allergens.
. Lab data: Nsg Dx : PI : P Exam ABG’s -do-do- ELIZA INEFFECTIVE AIRWAY CLEARANCE Airway – Endotracheal Tube (Tracheostomy Set . viocase) GIVEN WITH EACH MEALS Effective : if (-) fat at stool Hx Teaching : Refer parents to GENETICIST CROUP DISORDER ACUTE LARYNGITIS LTB (Laryngotracheal Bronchitis) RSV/ BRONCHIOLITIS (Respiratory Synctial Virus) common in TODDLER VIRAL Inflammation of LARYNX “barking-metallic cough” (-) FEVER (+) STRIDOR INFANTS & TODDLER VIRAL or BACTERIAL INFANTS usually (less than 6 mos) VIRAL Inflam.Common Complications: MALE – because of thick mucus plug Aspermia – low sperm count Sterility FEMALE – Difficulty in conceiving Nsg Dx : Knowledge Deficit Altered Elimination Altered Sexual Functioning Sweat Chloride Test – N (if sweat) 10 – 35 mg/dl – INCREASE IF (+) CF (if serum) 90 – 110 mg/dl -do- Lab Data : PI : since two system are affected: Respiratory Therapy – blowing of trumpet. Increase Fluid Intake. pancrease. GI Therapy – Administer Pancreatic Enzyme (pancreatin. of LARYNX & TRACHEA Inflam. Of BRONCHIOLES “harsh-brassy cough” (+) FEVER-low grade (+) STRIDOR “paroxysmal-hacking cough” (+) FEVER-moderate (+) WHEEZING STRIDOR – is present when the affected part is LARYNX. Humidity – place infant in MIST TENT or CROUPETTE Nsg care: change clothing frequently coz mist will dampen child clothings.#1) – to facilitate airway.
TOYS while inside the tent: PLASTIC TOYS “no battery operated & no friction wheel toys” at HOME: we can use NIGHT or MOIST air outside and hot shower mist at the comfort room – for child to inhale Antibiotics – Antiviral – Ribavirin Hx Teachings : SYRUP OF IPECAC – for Croup – it induces vomiting.bec it will stop the spam thereby preventing further coughing. Meds: Bronchodilator – Atrovent . Chronic Obstructive Pulmonary Disease (COPD) MP : group of disorders of respiratory system that lead to obstruction or narrowing of airways. BRONCHITIS ASTHMA EMPHYSEMA Over distention of Alveoli Risk Factors: (+) (+) (+) (+) (+) S/S: Inflammation of Bronchus Gelatinous sputum + “RE TACHY TACHY D C” Allergy Environmental factors Pollen Elevated Immunoglobulin E (IgE) Smoking (esp to passive smokers) RE TACHY TACHY D C + “barrel-shape test” – there is an INCREASE in ANTERIOR and POSTERIOR DIAMETER of the chest Lab Data : ABG’s – to check for respiratory acidosis CXrays Nsg Dx : #1 Ineffective Airway Clearance – due to narrowing & obstruction #2 Ineffective Breathing Pattern PI : AIRWAY 1-2 L/min.
LEGIONARES DSES – acute bronchopneumonia in elderly.due to rupture of BLEB – Tension Pneumothorax – due to INCREASE IN TENSION over distention of alveoli Diminished Breath Sounds – (-) b. (+) Restlessness Impaired Gas Exchange Ineffective Breathing Pattern Nsg Dx : PI : Chest Tube Drainage System – restores the (-) pressure within the thoracic cavity Anterior chest tube – drains the AIR Posterior chest tube – drains FLUIDS PNEUMONIA (PNA) MP : there is INFLAMMATION of ALVEOLAR SPACES that leads to exudation and consolidation of the lungs. Exercise: Blowing. (+) Dyspnea. alcoholic & Immunosuppressed pt .management same w/ pna VIRAL PNA Fever : Cough : WBC : Lab Data : Nsg Dx : PI : • • • • • • (+) low-moderate BACTERIAL PNA (+) fever moderate-high (+) Non productive – “thin-watery” (+) Productive – “rusty” No change or slight Xray and ABG’s Impaired Gas Exchange – due to exudation and consolidation of Alveoli Airway – O2 Position : Semi-fowler’s or Orthopneic Bed Rest Inc Oral fluid intake Antibiotics TCDB (turning. & deep breathing) Elevated . sounds to area auscultated. the POSITION OF CHOICE : ORTHOPNEIC PNEUMOTHORAX MP : partial or total collapse of lungs due to: Types : • • • S/S : Open Pneumothorax – TRAUMA Spontaneous Pneumothorax . coughing. Rest periods in between activities During ACUTE attack.
supports a dx of cystic fibrosis – MECOMIUM ILEUS in the neonate. d. if you are the nurse incharge. low grade fever that occurs in the afternoon. weight loss Lab Data : Histoplasmine Skin Test – for Histoplasmosis Mantoux Test Xray – confirmatory test Sputum . the primary goal of care for pt w/ bronchiolitis is to – minimize oxygen expenditure. Ineffective Breathing Pattern • MEDS : PROPHYLACTIVE TREATMENT OF TB – Antiviral Meds INH for TWO WKS (take Vit B6 to avoid NEUROPATHY) Antibiotics Rifampicin INH Streptomycin Ethambutol - take above meds for 6-12 moths to avoid resistance TIPS FOR RESPIRATORY you observed a nurse caring for a child in a CROUPETTE. b. e.@ least 2 (-) to be effective Nsg Dx : Infection. which data in the past medical history of the pt. coughing w/ bld streaked sputum. w/c of the ff intervention being carried out by LPN would require immediate intervention – suctioning the pt for 20 seconds. what would be your #1 PRIORITY? – changing the linens & clothings to keep child always dry. c. . body malaise or weakness.TB HISTOPLASMOSIS MYCOBACTERIUM AVIUM COMPLEX Bacterial Bacterial Fungal (from HISTOPLASMA CAPSULATUM) from BIRD MANURE – soil & transmitted thru inhalation Droplets & Airborne Droplets & Airborne Risk Factors: ASIAN IMMIGRANT IMMUNOSUPPRESSION MALNUTRITION Droplets & Airborne S/S : same: a to e + FOREST RELATED ACTIVITY Ask client if came from AVIARY same with TB a. initially asymptomatic.
Involve the parents of the child. Explain the methods of gathering the specimen Consideration for PEDIATRIC PATIENT a. a pt is diagnosed w/ emphysema – w/ of the ff s/s would the nurse expect to have – barrel shape chest.low grade fever. DIET and Keypoints : . a client w/ TB will experience . temperature S/S of Shock Specimen characteristic is usually affected by STREE. a nurse caring for a pt w R Lower Lobe PNA shld put the pt in w/c of the ff position to enhance postural drainage – L Lateral w/ the Head Lower than the Trunk DAY 7 (Feb 10. self insulin administration – allowed to child 9 yo and above Reportable S/S : skin changes – “have you noticed any change in your skin color” (“bronze skin pigmentation – addison’s dses) 2 servings of popcorn – HOW MANY RICE TO GIVE UP = 1 if sandwich = 1 rice Inc. 2005) ENDOCRINE General Consideration Explain to the pt the MOST COMMON METHOD of assessment: a. Direct methods – specimen : blood and urine b. Incorporate food preferences c. b.
vomiting and eczema – and by about 6 mos. Therefore (-) PH leads to accumulation of phenylalanine at the brain that leads to Mental Retardation. signs of brain involvement appear. S/S : Initially – asymptomatic For OLDER CHILDREN : AUTOSOMAL RECESSIVE PATTERN of transmission (inherited) Since (-) melanine: Lab Data : Diarrhea Anorexis Lethargy Anemia Skin Rashes and seizure Musty odor of urine (due to phenyl pyruvic acid) hair : blonde Eyes: blue Fair Skin Nsg Dx : GUTHRIE CAPILLARY BLD TEST – initial screening – done after the infant has ingested CHON for a minimum of of 24 hrs.prepare special education to parents Provide list of foods allowed.prepare special education to parents Refer to geneticist Untreated PKU can result in failure to thrive.Normal Body Rhythm PKU MP : There is Absence of Phenylalamine Hydroxylase (the one that converts Phenylalamine to Thyroxine ( a precursor to Melanin). Secondary screening : done when the infant is about 6wks old – test fresh urine w/ PHENISTIX – WHICH CHANGE COLOR Phenylalanine level greater than 8mg/dl – diagnostic of PKU (4mg/dl – indicative) Knowledge Deficit Altered Thought Process Risk For Injury PI : MEDS : Hx Teachings : Dietary Modification : LOW CHON and Low Phenylalanine Diet until adolescent or til 10 yo – bec b4 this time the brain mature Lofenalac – 20-30mg/kg/day Inform parents of the foods to be avoided.. . LYMPHOCYTIC THYROIDITIS or JUVENILE HYPOTHYROIDISM Cause : MP : S/S : Autoimmune or genetics Decrease in T3 and T4 Dysphagia Enlarge thyroid All s/s of hypothyroidism (decrease metabolism) .
Parrys) . 6. Decrease T3 and T4 Knowledge Deficit Risk for Injury Single morning dose of Synthroid for “LIFE” – oral thyroxine and Vit D as ordered to prevent M. Without treatment. Low calorie diet : since there is decrease metabolism. newborns are supplied with maternal thyroid hormones that last up to 3 mos. retardation (adverse effect of meds : insomnia. 3. 2. 7. Basedows.they secrete the hormone directly to bld stream Pineal Gland Pituitary Gland Thyroid Gland Parathyroid Gland Thymus Gland Pancreas Adrenals Gonads (testes & ovaries) Glands PITUITARY THYROID UNDER Diabetes Insipidus Hypothroidism (Myxedema) OVER SIADH Hyperthyroidism (Graves. Special education ENDOCRINE GLANDS 1. mental retardation and developmental delay will occur after age 3 mos. 4.Nsg Dx : PI : Knowledge Deficit Activity Intolerance no tx because it regresses (only temporary) spontaneously CRETENISM or CONGENITAL HYPOTHYROIDISM disorders related to absent or non-functioning thyroid. initially asymptomatic s/s begins 2 – 3 months behavioral s/s . 8. 5. and nervousness – REPORT ASAP) Lab Data : Nsg Dx : Meds : PI : correct the deficiency Hx Teachings : Warm environment (bec there is Hypothermia w/ cool extremities). tachycardia. 8 glands (ductless).apathy – “well behave” physical s/s – - large tongue & protrudes from mouth retarded growth intolerance to cold mental retardation Prevention: neonatal screening blood test.
OBESE. Maturity Onset that occurs in young adult.PARATHYROID Pancreas ADRENALS Hypo DM Addison’s Dses Hyper Cushings Conns PANCREAS Alpha Cells BETA CELLS Islets of Langerhans Glucagon Insulin (responsible for Decrease in blood sugar) Responsible in the increase Blood Sugar Absence (DM Type I) IDDM Juvenile Onset – B4 age of 30 Adolescence to Early Adult Stage Pt is THIN Pt is KETOSIS PRONE Deficiency (DM Type II) NIDDM Maturity Onset – After age of 30. Pt is Obese NON-KETOSIS PRONE MODY – DM III combines features of DM Type I & 2. b4 age of 30 Non-Ketosis Prone GESTATIONAL DIABETES .occurs during pregnancy Types According to WHITE’S Classification TYPE ONSET DURATION .
Cause: unknown Autoimmune Genetic Stress Polydipsia Polyuria Polyphagia Wt loss R. factors : S/S : – the stave cells send message to the brain to eat more Nsg Dx : PI : Knowledge Deficit Altered Nutrition Correct the deficiency.HOW? Diet : well balance diet – CHO – 50-70% (main source of energy and sugar for DM pt.) Insulin – for Type 1 Hypoglycemia Most Approximately to Occur RAPID INTERMEDIATE SLOW INSULIN: Regular Insulin .BEFORE LUNCH NPH .LATE IN THE AFTERNOON/ AFTERNOON Protamine Zinc .DURING NIGHT Ultralente Best Site is ABDOMEN bec it is a NEUTRAL AREA .A B C D CHEMICAL DIABETES (+) Increase Bld Sugar After the age of 20 Bet 10 – 19 yrs old Before 10 yrs old 10 years 10-19 years More than 20 yrs D1 D2 D3 D4 D5 Before 10 yrs old >20 yrs Beginning Retinopathy w/ calcification of arteries DM w/ HPN w/ calcification of Pelvic Arteries w/ nephropathy (Diabetes Nephropathy) Diabetes Cardiopathy Diabetes Retinopathy w/ Transplant of the Kidney E F H R T DIABETES MELLITUS MP : Deficiency in INSULIN – either absence or deficiency of insulin that leads to alteration in the metabolism of CHO. CHON and FATS.
cut toe nail across .SUBQ – 90 degree angle for insulin syringe 40 degree angle if non-insulin syringe Complication of INSULIN ADMINISTRATION: Lipodystropy Dawn’s Phenomenon – hyperglycemia that occurs at dawn – Early AM .due to over secretion growth hormone treatment: GIVE INSULIN – NPH at 10 PM to prevent hyperglycemia at early AM (tx: administer insulin) Antidiabetic Agent. snugly fitting shoes. Transplant of Pancreatic Cells. Exercise – it will decrease insulin requirement Scrupulous foot care (in pregnancy/stress – Increase insulin req) – check up w/ podiatrist . AM Dose: PM Dose: EFFECTS 2:1 for Regular to NPH 1:1 for R:NPH MOTHER Macrosomia Hyperglycemia Therefore pre-term birth Complication: Uterine Atony BABY Hypoglycemia RDS Congenital Defects COMPLICATION 1.avoid going barefoot .foot powder. SOMOGYI Phenomenon – rebound hyperglycemia Blood Sugar Monitoring – in AM and supper time (2x a day).BLD SUGAR BELOW 50 DKA Risk Factors : Missed meals.always dry in between toes Modification for Pregnant Pt with DM • • +300Kcal. Insulin Requirement (dose will be adjusted on 2nd & 3rd Trimester). cut toe nail straight across . Ensure adequate food intake. Hypoglycemia (Insulin Reaction) . Hyperglycemia (bld sugar level above 120) (Diabetic Coma) HHNK Overeating Decrease Insulin . Increase or Overdose of Insulin.
. Diaphoresis Lab Data : Below 50 Blood Sugar Level PI : Administer Simple Sugar (fructose-fruit juice) Hard Candy (not chocolate – it is complex sugar) If unconscious – D50 DKA (Type 1) HHNK (Type 2) (Hyperglycemic Hyperosmolar Nonketotic Coma) S/S : 3 P’s + Signs of Dehydration – thirst & warm skin Hyperglycemia “Kussmaul Breathing + 3P’s Thirst and warm skin Lab Data : PI : Increase Bld Sugar #1 AIRWAY #2 Fluid Regular Insulin Risk for Injury More pronounced GI Disturbances Nsg Dx : 2. 5. - MICROANGIOPATHY . 3. S/S : Too much Activity Inactivity Stress Infection Dizziness Drowsiness Difficulty Problem Solving Decrease Level of Consciousness + Cold Clammy Skin. 6.w/c leads to cataract (eye exam annually). ATHEROSCLEROSIS – NEPHROPATHY OPTHALMOPATHY – kidney damage. 4. Peripheral Neuropathy or Autonomic Neuropathy there is poor nerve impulse transmission common manifestation : impotence DIABETES INSIPIDUS .destruction of small blood vessels. hardening of arteries.
Prolactin PITUITARY GLAND ADH (anti Diuretic Hormone) – retain h20 or flds Deficiency: lead to D.pt on NPO 24hrs B4.(Pituitary Glands – 3 lobes) ANTERIOR Secrete Tropic Hormones POSTERIOR Store Only (does not excrete) MIDDLE MSH (skin color) FSH OXYTOCIN (follicle stimulating Hormone) ADH ACTH (adrenocorticotropic hormone) LH (luteinizing hormone).010 – 1. therefore s/s same with DM EXCEPT : POLYPHAGIA LAB DATA : a. INSIPIDUS Excess : SIADH (Syndrome of Inappropriate Anti Diuretic Hormone Secretion) Due to or related to: Pituitary Tumor Head Trauma Injuries MP : Deficiency in ADH leads to fld excretion.025) – in DI its <1. Evaluate the effect of meds : Check Specific Gravity of Urine. urine . b.decrease in specific gravity (N 1. Monitor V/S : assess for hypovolemic shock . Nsg Dx : PI : FLUID VOLUME DEFICIT Administer IV Fluids Meds .Vasopressin – IM Desmopressin – INTRANASALLYLypressin -doHow : Polyuria – 21 L/day Polydypsia one hole of nose only Given as pt exhale to the mouth then inhale thru the nose then EXHALE to the mouth then give meds.005.Synthetic ADH . GH (growth hormone). FLUID DEPRIVATION Test . Monitor I & O.
shoe size) ex. in Height ex. slender extremities and Inc. MAHAL EXCESS B4 Closure of Growth Plate . seizure.“congenital” ex. MP : Fluid Retention – result to DILUTIONAL HYPONATREMIA or H2O INTOXICATION S/S : due to DECREASE NA – this could lead to the ff: convulsion.“gigantism” .long.there is coarsening of facial features + enlargement of the digits (inc. HPN Above s/s could lead to decrease LOC LAB DATA : Decrease Na Level (<120 mEq/L) – hyponatremia Nsg Dx : PI : FLUID VOLUME EXCESS FLUID RESTRICTION Drugs – DIURETICS + ANTIHPN – if cause by TUMOR – PREPARE PT FOR SURGERY IF after surgery – POLYURIA – report ASAP – sign of DI PITUITARY GROWTH HORMONE DEFICIENCY DWARFISM . Balingit Lab Data : INCREASE HUMAN GROWTH HORMONE .SIADH excess ADH. Marlo Aquino NANU’S SYNDROME (hereditary) After the Closer of Growth Plate .“acromegally” .
w/c cause K EXCRETION & Na RETENTION MP : Underactivity of the Adrenal Glands Overactivity of A. Glands (there is DEC G.Parlodel – decrease secretion of growth hormone If related to tumor : surgery GIGANTISM (long slender extremity) MARFAN SYNDROME (hereditary) MP : Cardio & Eye disorder Scoliosis (complication) KLINEFELTERS (chromosomal aberrations) MP : XXY Pattern (an extra X chromosome) X chromosome – FEMALE COMPONENT of HUMAN BODY Problem is NON-DEVELOPMENT of SEX ORGAN ADRENAL/SUPRARENAL CORTEX (OUTER) RESPONSIBLE FOR SECRETION OF: MEDULLA (INNER) SECRETES THE FF: GLUCOCORTICOIDS MINERALOCORTICOIDS (ALDOSTERONE) EPINEPHRINE NOREPINEPHRINE GLUCONEOGENESIS STRESS RESPONSE – “fight or flight” . M & SEX HORMONES) (there is INCREASE G & M) ADRENOCORTICAL INSUFFICIENCY . MINERALOCORTICOIDS .formation of sugar from Responsible for Na Retention new sources and K Excretion DEFICIENCY IN GLUCO & MINERALO : EXCESS of GLUCO & MINERALO : ADDISON’S Dses CUSHING’S Dses/ syndrome EXCESS of MINERALOCORTICOIDS ONLY : CONN’S SYNDROME ADDISON’S CUSHING CONN’S INC.Increase Blood Sugar Nsg Dx : PI : Risk for Injury Safety Meds .
Inc K Prevent exposure to Infxn Provide rest periods – prevent fatigue Monitor I & O. report s/s of Addisonian Crisis – severe HYPOTENSION Avoidance of strenuous exercise esp in HOT WEATHER Meds: FOR LIFE Glucocorticoids Synthesis Inhibitors . Excess Fld & E imbalance Risk for Injury Fld & E Imbalance ADDISON’S PI : CUSHINGS CONN’S Correct the imbalance – IV Diet: Inc Na Dec K Administer Steroids (Fludocortisone) Admin. Buffalo Hump. Age 30-60) RF : Could be related to Surgery – removal Related to Tumors Of Adrenal Gland and or Auto Immune Reaction S/S: Dec Bld Sugar (hypoglycemia) Dec Na (hyponatremia) Dec BP INC K (hyperkalemia) INC BP. Muscle weakness Nausea. Hirsutism.Lysodren and Cytodren . frequent feeding high in CHO.Excessive SECRETION of . Na and CHON to prevent Hypoglycemia & Hyponatremia Use of Table salt tablets (if Rx) or ingestion Surgery – prepare pt if cause Of salty foods (potato chips) by pituitary tumor or hyperplasia if experiencing Inc. Fatigue. Vomiting Hx of frequent Hypoglycemic Rxn Increase Cortisol Level Hypernatremia Hyperglycemia Hypokalemia Hypokalemia – due metabolic Alkalosis Inc Urinary Aldosterone Level Decrease K Lab Data : Decrease Cortisol Level Hyponatremia Hypoglycemia Hyperkalemia Nsg Dx : Fluid Vol. Anorexia. Weak Pulse Weight loss. observe for HPN & edema Administer SPIRONOLACTONE (aldactone) & K supplements Provide small. sweating Post Surgery: poor wound healing.prevents formation of Gluco… ADDISONIAN CRISIS . weigh Daily Protect client exposure to Infxn Minimize stress in environment MIO & weigh Daily As Rx Monitor V/S. K. Ca & Vit D Check BP – give antiHPN Limit the flds Meds are FOR LIFE Prevent accident & Falls Diet : Low Na. Pendulous Abdomen Hypertension Lability of Mood (mood swings) Polyuria. Polydipsia Depression Cardiac Arrythmias – due COMPENSATORY of MSH – Inc w/c Trunkal Obesity / thin Extremities to dec K Leads to “Bronze-Like Skin Pigmentation” Hypertension Decrease Resistance to Infxn Hypotension. Cortex Female (30-50) Related to Tumor Common: Male and Female Female (bet. Deficit Fld & E imbalance Fld Vol. NA ALL S/S OF CUSHINGS DEC K + EXCEPT HYPERGLYCEMIA Moonface. Hormone Replacement Therapy Cortisone – give 2/3 of dose in AM 1/3 in afternoon Correct the imbalance .coticosteriods especially the GLUCOCORTICOID CORTISOL Excessive ALDOSTERONE Secretion from A.limit fld intake DIET : Low in Calories & Na High in CHON.
stress. failure to take RX Meds severe generalized muscle weakness severe hypotension hypovolemia.causes: s/s: severe exacerbation of Addison’s dses caused by acute adrenal insuffieciency strenuous activity. Basedow’s or Parry’s Dses Slowing of metabolic process caused by hypofunction of the Secretion of excessive amount of Thyroid Thyroid Gland with decrease thyroid hormone secretion (T3 & T4) Hormone in the blood causes in the INC Of metabolic process DEFICIENCY in T3 and T4 Causes: Excess in T3 and T4 S/S : congenital surgery autoimmune genetic autoimmune tumor FACIAL EDEMA INTOLERANCE to COLD DECREASE v/s DECREASE GI Motility – constipation HYPOactivity Increase Sleep – hypersomnia Wt Gain in the presence of Dec Appetite Dry scaly skin. shock administer flds to treat vascular collapse IV glucocorticoids . trauma.responsible for maintenance of METABOLISM Calcitonin .Solu-Cortef and Vasopressors Maintain strict bed rest and eliminate all forms of stressful stimuli MIO and weigh daily Protect client from Infxn Other Hx teachings: same with Addison’s PI : THYROID T3 & T4 . nsg consideration : take a thorough history – thyroid meds must be D/C 7-10 days b4 the test – meds containing iodine cough preparations.performed to determine thyroid function (increase uptake – indicated hyperthyroidism. dry sparse hair. restlessness. and intake of iodine rich foods and test using iodine – eg IVP can invalidate the test . brittle nails EXOPTHALMUS (+) Goiter Hypermetabolic State INTOLERANCE to HEAT Inc V/S INC GI Motility . fine soft hair Pliable nails Irritability. agitation LAB DATA : Check TSH (increase) DECREASE T3 & T4 DECREASE RAIU (131) INCREASE Serum Cholesterol Level DECREASE TSH INCREASE T3 & T4 INCREASE RAIU RADIOACTIVE IODINE UPTAKE (RAIU) – administration of 123I or 131I orally.DIARRHEA Insomnia HYPERactivity WT LOSS even INC Appetite Warm smooth skin.deposit Ca @ bones DEFICIENCY HYPOTHYROIDISM Adult: Myxedema Children: Cretenism Main Problem: EXCESS HYPERTHYROIDISM Grave’s Disease. infection. . minimal uptake may indicate – hypothyroidism).
can be diluted w/ H2O or orange/ apple juice. PTU & Lugols Assign to private room away from excessive activity Quite & relaxing Activity Provide a COOL ENVIRONMENT DIET : High in CHO.give w/ straw to avoid staining teeth. CHON. Sweating. Antithyroid Drugs – Prophythiouracil and Tapazole . .hyperthermia .block synthesis of thyroid hormone. tremors.. dyspnea Risk for Injury (bec of hyper) same Admin AntiThyroid Meds – for LIFE ex. ask pt to talk past surgery and if pt has APHONIA – provide communication aids – paper and pencil LARYNGOSPASM – accidental removal of parathyroid gland – therefore will lead to dec parathormones – w/c lead to dec Calcium and laryngospasm – KEEP TRACHEO SET at bedside. Provide comfortable. . THYROID SUPPLEMENT Synthroid. Increase flds and high fiber foods to prevent constipation. Prepare pt for surgery – 2wks before SURGERY give LUGOL’S SOLUTION . DIET: low calorie c. warm environment e. Admin stool softener as Rx f. tingling sensation – fingers & lips b. To check. Maintain vital funx: correct hypothermia – maintain adequate ventilation d. Sore throat & skin rashes) – if taking antithyroid meds. Radioactive Isotope of Iodine (131) – Radioactive Iodine Thrapy .it decrease size and vascularity of thyroid gland.report diarrhea & metallic state Meds: a.given to destroy the thyroid gland thereby decreasing Thyroid hormone production COMPLICATIONS OF THYROID SURGERY: MEMORRHAGE – whether the dressing is dry or intact – its not a confirmatory that there is no bleeding. TETANY – due to decrease in CA – characterized by: a. . palpitation nervousness b. diarrhea. vomiting. slip your hands at the back of the neck (bec of principle of gravity) Damage Laryngeal Nerve – to assess. Cytomel – lifetime s/e: insomnia. Meds: thyroid hormone replacement – take daily dose in AM to avoid insomnia Monitor THYROTOXICOSIS – tachycardia Palpitations.NSG DX : Activity Intolerance – due to Fatigue (fatigue – due to hypometabolism) PI : HOW : Promote a EUTHYROID STATE a. Chvostek’s Sign – facial muscle twitching on percussion of facial nerve c.toxic effect include AGRANULOCYTOSIS b. . nausea. CALORIES Vit & Minerals w/ supplemental feedings bet meals & at HS NO STIMULANTS tears Protect eyes w/ dark glasses & artificial Monitor for AGRANULOCYTOSIS (fever. Trousseau Sign – carpopedal spasm THYROID CRISIS – due to rebound hyperthyroidism Increase thyroid hormone Increase HRate/palpitation Inc Temp .
Or caused by accidental damage to or removal Of parathyroid glands during surgery eg thyroidectomy Increased secretion of PTH that result in altered state of Ca.5 mg/dl) Dec Serum Phospate Level xray –reveal Bone Demineralization Inc Oral Fld intake – due to renal calculi of having INC Ca Diet. Keep Ca supplement at Bedside c. sardines. Phospate & bone metabolism S/S : Initial S/S: Tingling lips & Fingers Chvostek’s Trousseau personality changes cardiac arrythmias muscle pains Late S/S - Bone Pain (esp Back Bone) Kidney Disorder – kidney stones renal colic NAV. Safety b. Diet: Inc Ca – spinach. Constipation Lab Data : Decrease Ca Serum Phospate Inc Skeletal Xray – reveal Inc Bone density Nsg Dx : PI : RISK FOR INJURY a. seafoods d.5-5. Low Ca Surgery – if due to tumor . Tracheo set – deu to dec Ca – Laryngospasm same same Inc Ca (N 4.PARATHYROID Parathormone HYPOPARATHYROIDISM Deficiency Inc CA in the Blood withdraws Ca @ bone to the bld EXCESS HYPERPARATHYROIDISM MP : Dec Ca (hypocalcemia) maybe hereditary.
the nurse anticipates that the doctor will most likely order – Ca Gluconate. . when shld the nurse expect to have hypoglycemia – in the late afternoon.w/c has INCREASE Phenylalanine.TIPS FOR ENDOCRINE a child w/ PKU was admitted. what would be the question to support the Dx of Hypothyroidism – do you tire easily?. rapid & deep breathing that occurs in diabetic pt is indicative of – KETOACIDOSIS a pt is to receive NPH Insulin at 8AM. a pt post thyroidectomy develops tetany. w/c of the ff statements made by the diabetic pt would indicate the need for further teaching – “I will be hypoglycemic if I experience emotional stress”. w/c of the ff statements made by the mother indicates a need for further instruction – “my child loves to drink milkshakes” – chon. the expected outcome is – Dec HR. w/c of the ff if manifested by a child could be indicative of diabetes – bed wetting. to determine the effect of PTU. a common manifestation of HYPOGLYCEMIA – shaky tremors.
if INCREASE . Mellitus . s. characteristic of urine: color N . check for wt gain if >1lb/day – indicative of fld retention b. use open-ended question.amber if pinkish – bldg brownish – flagyl orange – rifampicin c. bladder trng comes after bowel trng – 15-18 mos of age) S/S common to all Disorders of GU: a. bladder sphincter control develop at around 2 yo (therefore. hesitancy Reportable s/s : peri orbital edema BP Oliguria Hematuria – Early Stream Hematuria – indicate lesion at Urethra Late Stream – indicate lesion at bladder Key points : a. bladder capacity increase with age infants – about 65ml toddler – 300-400 ml school age – 800 – 1000 ml infants are unable to concentrate urine until the age of 1 – therefore – adequate milk intake if baby has 6-8 diapers /day. Consideration for Pediatric Patient assess for history of sorethroat.GENITO-URINARY General Consideration when performing assessment of Genito-urinary system. ask the patient what symptoms bother him/her the most.010 – 1.D. gravity (N 1. explain the meaning of terminologies. urgency c. Insipidus DECREASE – D.025) .bec some pt are not comfortable talking genitals. frequency b.
d. Low Na LOW CHON and Na . severe .<10 mg/ 24hrs urine Nsg Dx : Fld Volume Excess Impaired Skin Integrity PI : Check BP Maintain Fld Balance Meds : NO Antihypertensive (+) Steroids (+) Antibiotics Antihypertensive Diuretics DIET : INCREASE CHON. Elevated CHON – Nephrotic Syndrome or PIH Epispadias – opening at DORSAL portion Hypospadias – opening at VENTRAL portion WILM’S TUMOR S/S : congenital tumor at the kidney common in L Kidney and children below 5 yo Unilateral Abdml Mass Hematuria HPN Lab Data : CT Scan IVP NO INAVSIVE LAB/ Procedure NO BIOPSY Nsg Dx : PI : Knowledge Deficit Risk for Injury AVOID/ NO ABDOMINAL PALPATION Prepare pt for Surgery and Chemotherapy NEPHROTIC SYNDROME (therefore there is PROTEINURAI) causes: Autoimmune congenital AGN to Group A Beta Hemolytic Streptococus sorethroat MP : Altered Kidney Funx related to inability to retain CHON Destruction of Kidney Tissues related S/S EDEMA: Peri-orbital Edema but subside at the end of the day Periorbital but progresses to generalized at the end of the day INCREASE BP Tea colored or Cola colored or Smoky BP : URINE : Decrease or N Frothy LAB DATA (+) Proteinuria. Increase glucose – UTI e.>10mg in 24 hrs (+) Proteinuria .
AGN Post-Renal – those that causes obstruction eg.Phase I: RENAL INSUFFICIENCY Intra-Renal – dses condition of the kidney eg.use COTTON Bubble bath Prolong driving Common in FEMALE – due to size (short) urethra S/S: FREQUENCY.renal funx normalizes LAB DATA Increase BUN and Crea – most sensitive Index . . Fld Intake RENAL FAILURE ACUTE MP Sudden or Acute.Dec Na & K RECOVERY PHASE .Inc urine output (4-5L/day) . URGENCY & HESISTANCY + Burning sensation on urination (dysuria) LAB DATA : Nsg Dx : PI : Diet : Infection of the bladder Ascending infection caused by E.Dec NA & Inc K DIURETIC PHASE . Kidney stones Polyuria Nocturia Polydipsia PHASE II : MILD RENAL DAMAGE (OLIGURIA) RENAL FAILURE All s/s + Anemia & HPN ESRD (1-2 yrs) Azotemia & Uremia – accumulation of waste products “uremic frost” – skin pruritus same There will be INC BUN & Crea OLIGURIC PHASE . effective : (-) pain) Hx Teachings: Avoid bubble Bath No Silk underwear Inc. PYRIDIUM – ch can cause ORANGE COLORED URINE.POSITIONING : Turn Patient frequently – because pt w/ edema are prone to skin integrity like pressure sore formation CYSTITIS RF : Wearing silk underwear (does not absorb moist). – SHOCK.decrease urine output that is less than 400 ml/24hr . Usually Reversible loss of Kidney Funx There is inability of kidney to maintain fld & E balance CHRONIC IRREVERSIBLE kidney damage that leads to scar formation Causes PHASES : Phases of ARF Pre-renal Factors – those that dec bld circulating vol. Coli (from feces) or Pseudomonas Urinalysis – to check for microorganism Altered Elimination Pattern Infection Treat for Infection – antibiotics for 10-15 days ACID-ASH DIET – give lemon juice or VIT C Bladder Analgesic (ex.
DIALYSIS ENCEPHALOPATHY – due to aluminum toxicity s/s: (+) dementia muscle abnormalities – twitching seizures RENAL TRANSPLANT – s/s of complication : FLANK PAIN. seizures 2. Fluid restriction. vomiting.convulsion. TENDERNESS. DIET : Low CHON – NO PMS DIALYSIS PERITONEAL Semi-permeable membrane: Abdomen (peritoneum) Use of Tenchkoff Catheter Teachings: HEMODIALYSIS Dialyzing machine Use of fistula or shunt anastomosis of artery & vein (internal access) – less prone to infxn Report Infxn (abdomen: rigid. FEVER. HPN .REPORT BPH S/S : Decrease size and force of urinary stream Nocturia Frequency. DISEQUILIBRIUM SYNDROME – due to rapid removal of solutes (electrolytes and CHON) s/s: GI – nausea. ky jelly position: Sim’s Altered Elimination Pattern Prepare pt for surgery TURP – no incision Suprapubic Prostatectomy Retropubic -do Perineal -do. Meds : Diuretics Cardiac Glycosides – Digitalis Antihypertensive Fld restriction Amphogel – to promote excretion of Phospate Epogen – Inc RBC synthesis Diuretics AntiHPN Diet: same C. hesitancy and urgency LAB DATA: Digital rectal exam – once a yr for pt 40yo and above gloves. headache CNS .. Solution : cloudy) Check BT and CT Check Temp of dialyzing solution external access (more prone to infxn) Complications of dialysis (report ASAP): 1.common complication: IMPOTENCE due to nerve damage “I am eager to have sex again” – cannot be bec pt is impotence glandular enlargement of the prostrate common in males above 40 yrs old Nsg Dx : PI : .Nsg Dx Fld and E Imbalance Fld & E Imbalance Activity Intolerance PI : TO CORRECT THE IMBALANCE A. B.
To prevent cystitis. For early detection of prostrate CA the nurse shld emphasized – digital rectal exam annually to screen for prostrate CA in men 40 yo and above. w/c of the ff is appropriate action – turn pt to side.nsgcare : CBR for 2-3 days post surgery. NO LONG DRIVE/ SITTING. Ff up check up (if INC ACID PHOSPATASE: Prostate CA) TIPS FOR GENITOR-URINARY A common sign of ARF – OLIGURIA. w/c of the ff the nurse must instruct to the pt to do – take a bath using the shower rather than bubble bath. After peritoneal dialysis. the nurse shld expect that the pt will probably have the symptoms – residual urine of more than 50 ml. w/c of the ff indicates complication of peritoneal dialysis – cloudy dialysate . w/c behavior would indicate that the pt needs further instruction in self care – he wears a watch on his L wrist. In a pt with BPH. A male pt has an arteriovenous fistula in his L forearm.
buzzing or sea shell sound in the ear VERTIGO .DAY 8 (Feb 11. Explain the methods of assessment to the patient.Objective – “the room is spinning” Subjective – “I feel that I am revolving/rotating” Hearing Loss Pain – if pain subside or (-) – rupture of ear drum Keypoints for Assessment Note for abnormal findings Document the subjective and objective complaints OTITIS MEDIA RF : Faulty feeding practices Swimming in dirty waters Upper Resp.ringing. Consideration to Pediatric Patients Obtain feeding history (bec the type & techniques differs) Obtain the diet hx of the pt and hx to URTI Involve the parents in the assessment of the baby Reportable Signs and Symptoms TINNITUS . bulging tympanic membrane infection of the middle ear Nsg Dx : PI : Infection Sensory – Perception Alteration Treat Infection (antibiotics – 7-10 days) – if does not heal – possible MYRINGOTOMY Hx Teaching : RIGHT POSITION while feeding . 2005) EENT General Consideration Explain to the patient there there will be no or little discomfort when performing EENT exam. Tract Infection S/S : PAIN – Pulling Tugging Crying when lying on the affected ear Absence of pain indicates rupture of Tympanic Membrane – ear drum Lab Data : OTOSCOPY – revealed – reddened.
(No Bowling & shampooing of hair at sink) . genetically transmitted.RETINOBLASTOMA S/S : congenital tumor of the retina. Syndrome are prone RETINAL DETACHMENT MP : There is separation of sensory and pigment portion of the retina – therefore it will allow fluids to go in between which give rise to OUSTANDING manifestation as: VISUAL FLOATERS – pt says: “I see light structures Curtain like Floating spots Cobwebs” S/S : NO Pain Blurring of vision – because of floaters Opthalmoscopy Risk for Injury Immediate Bed rest – AFFECTED SIDE TOWARDS THE BED – to allow the connection of DETACHED PART NO SUDDEN HEAD MOVEMENT AVOID reading (TV – ALLOWED) Prepare Pt for Surgery: SCLERAL BUCKLING – use of laser to reduce inflammation and when inflammation subside.whitish or grayish discoloration of the pupil Diplopia and or Strabismus LAB DATA : Nsg Dx : Tx : PE Opthalmoscopy Knowledge Deficit Surgery – Inoculation – done b4 age of 3 (chemotherapy – after surgery) Genticist RETINAL DETACHMENT RF: Aging (above 40) Related to trauma GLAUCOMA Aging (above 40) CATARACT Aging (above 70) Common in Blacks Related to Trauma Familial Predisposition Rel. COUGHING.those with D. autosomal dominant (common in MALE and FEMALE) LEUKOCORIA – “cat’s eye reflex” . to Diabetes Rel. to Chromosomal Abberation . the detached retina portion will be attached thru scar formation. to Steroids Rel. LIFTING. Lab Data : Nsg Dx : PI : POST SURGERY : AVOID activity that requires BENDING.
Diamox) – for LIFE . Administer MIOTICS (Pilocarpine. TREATABLE but NOT CURABLE If Obstruction related : could lead to CHRONIC OPEN ANGLE. Chronic G . Tomolol.it decrease the production of ACQEOUS HUMOR – admin. At lower conjunctival sac b. . REPORT SUDDEN eye pain – indicative of bleeding/ hemorrhage GLAUCOMA MP : INCRASE IOP due to obstruction in the outflow of acqeous humor or could be related to forward displacement of the iris.as high as 50 Nsg Dx : PI : Gonioscopy Opthalmoscopy Perimetry – measures visual field Risk for Injury TO DECREASE IOP How: a.Out-patient only (use of laser only) TRABECULECTOMY – Hx Teachings : same w/ retinal detachment requires hospital admission for 1-2 days . If due to Forward displacement: can lead to ACUTE CLOSE ANGLE S/S : TUNNEL or Gun Barrel Vision – wherein there is loss of Peripheral Vision Halos around lights – rounded rings around eyes CLOSED ANGLE GLAUCOMA – (+) pain OPEN ANGLE GLAUCOMA – minimal or (-) pain LAB DATA: Tonometry – measures IOP (N12-21) – PAINLESS ACUTE G – as high as 25. Prepare pt for Surgery : TRABECULOPLASTY – a new pathway was created for the passage of the blocked fluids.
Detachment MENIERE’S DSES RF : High altitudes Aging Ototoxic Drugs Cause by an imbalance of EndoLymphatic Fluids in the inner ear Sensori-neural hearing loss – since Inner ear was affected S/S : Tinnitus Hearing Loss + VERTIGO (only for M. Opthalmoscopy Nsg Dx : PI : Risk for Injury Prepare for SURGERY CATARACT EXTRACTION – Extra Capsular Cataract Extraction (ECCE) Intra Capsular Cataract Extraction (ICCE) ECCE – removal of anterior part ICCE – removal of entire capsule PHACOEMULSIFICATION .CATARACT MP : Opacity of the Crystalline Lense S/S : Blurred Vision (Poor Color Perception) NO PAIN LAB DATA: a.since middle ear was affected same same Lab Data: Weber’s test – lateralization of sound Rinne’s – bone conduction Audiometry (above test – use of TUNING FORK) Nsg Dx : PI : Risk for Injury SAFETY (to prevent pt from falling: bedrest or supine – danger of falls) Sensory Perceptualalteration Establish Communication Surgery : STAPEDECTOMY – mobilization of stape . DSES) Caloric Stimulant test OTOSCLEROSIS (hardening of the ears) Aging MP : Overgrowth of the stapes Conductive Hearing Loss . SLIT LAMP TEST – test for red light reflex (this reflex is absent in cataract pt due to presence of milky white lens) b.needle is inserted to lens and send vibration thereby crushing the cataract then suction it out PERIPHERAL IRIDECTOMY – a whole is created then suctioning Post Cataract Surgery – NO SEX for 4-6 weeks Health teachings – same w/ R.
GENETICIST . w/c of the ff is a common manifestation of Retinoblastoma – Cat’s Eye Reflex. w/c Nsg Dx is considered a priority for a pt with Meniere’s Dses – Risk for Injury a Tonometer is used for the purpose – to determine IOP.driving PMS Sudden Head Movement Post Surgery Hx Teachings: AVOID – diving Small airplane Coughing Blowing of Nose Bending TIPS FOR EENT A pt who underwent cataract surgery w/ intraocular implantation is scheduled for discharge. the nurse shld instruct the pt to do w/c of the ff when pain occurs – notify the AP. Bonamine (-) Vertigo/ Falls AVOID . Post Cataract Extraction : how shld the nurse position the pt – UNAFFECTED SIDE to minimize edema. The parents of the pt w/ retinoblastoma must be referred to .DIET : Meds : Effective : LOW NA (AVOID – Alcohol & Caffeine containing food) AntiVertigo – Diamox.
Tachycardia. “bruit” – abnormal vascular sound w/c indicate abdml aortic aneurysm DIARRHEA/ AGE usually asso w/ NORWALK (common in ship). it will progress to shock – due to K loss (hypokalemia) LAB DATA : Stool Exam – to check for bacteria Nsg Dx : Diarrhea Fluid Volume Deficit Place pt on ENTERIC ISOLATION PRECAUTION – while waiting for lab result (handwashing & gloves ONLY) PI : .N 5-35 bowel sounds/min) .GASTROINTESTINAL GENERAL CONSIDERATION Provide privacy Ask the pt when he 1st notice the S/S Eg. ROTAVIRUS and CLOSTRIDIUM DEFFICELE MP : Passage of watery and loose stools (BEST judge in the consistency) S/S : Frequent stools Sign of DHN – sunken fontannels Poor Skin Turgor Absence of Tears (for more than 2 MONTHS old infant) Check for complication : Metabolic Acidosis If excess fluid loss. use DIAPHRAGM of Steth – to listen for normal sounds BELL part of Steth – to listen for abnormal bowel sound Ex. Dehydration – indicative of SHOCK Hypotention KEPOINTS… Bowel Sounds (check all 4 quadrants.to assess. LIVER CIRRHOSIS – when did you notice that your eyes turns yellow? PEDIATRIC CONSIDERATION Introduction of FOOD: (shld be in order) Cereals Fruits Vegetables Meat Table foods Obtain child Dietary History Assess for over-intake of milk – poor source of iron (IDA) REPORTABLE S/S Vomiting Abdl Pain (if more than 6hrs) – R/O rupture of the bowel Tarry Stool – indicates bldg (upper GI) Fever.
CHALASIA GERD CONGENITAL WEAKNESS OF THE CARDIAC SPHINCTER S/S: vomiting . juice. IDENTIFY the type of poison “if unknown substance was taken” – bring bottle or foil for proper identification TYPES: CORROSIVE – “DO NOT INDUCE VOMITING” Management: NEUTRALIZE the poison If STRONG ACID – give WEAK BASE (eg. b.NON-BILE-STAINED Hear-burn due to Reflux of Acid Complication : METABOLIC Acidosis BARRETT’S ESOPHAGUS LAB DATA : Upper GI Series (Ba Swallow) Gastroscopy Esophagoscopy do do do same same .30 ML CLEFT . therefore X100) Health teachings – crackers. water Feeding : Thickened Prepare pt for surgery : NISSINFUNDOPLICATION – part of fundus will be sutured to esophageal area to tighten Effective: if (-) vomiting and(-) reflux and heartburn POISONING INTERVENTION: a. Use fingers or tongue blade Syrup of Ipecac – administer w/ glass of H2O – make sure that all taken will be vomited – bec it is cardiotoxic (after 1hr – can repeat) dosage: CHILDREN – 15 ML ADULT . CALL poison control center.damage to mucosal lining of lower esophageal mucosa w/c can lead to esophageal CA Nsg Dx : Altered Nutrition Less Than Body Requirement Flds & E Imbalance PI : Insure Adequate Nutrition Position: Place pt in UPRIGHT – to avoid vomiting (if BABY: use HARNESS or PRONE w/ HEAD UP POSITION) Administer flds Antibiotics/ Antidiarrheals ( dosage: if less than 10 kg. b. ACID – give MILK) IF STRONG BASE – use weak ACID by using vinegar NON-CORROSIVE – induce vomiting by stimulating GAG REFLEX How: a. MINIMIZE EXPOSURE – remove pt from the scene c.
NON-BILE STAINED but eventually it PROGRESSESS TO bile-stained) If sitting : 4-5 ft If lying down : 1 foot Feeding should be thickened then AFTER FEEDING. ELBOW RESTRAINT – prevent child from touching the suture line.if child is 15-18 mos CRYING shld be minimize – bec it will put pressure at suture line.for 10wks old 10 lbs 10gms/hgb 10.000 WBC Post Surgery: (congenital) Surgery : Palate Uranoplasty .LIP MP: Non-fusion of facial process PALATE Non-fusion of Palative Processess (soft & hard) (congenital) Nsg Dx : Altered Nutrition Risk for Aspiration Body Image Disturbance PI : Nutrition Safety Prepare for Surgery Chiloplasty . AUDIOLOGIST & PSYCHOLOGIST PYLORIC STENOSIS - S/S : congenital hypertrophy (“kumapal”) of the pyloric sphincter (bet stomach & intestine) • PROJECTILE VOMITING (INITIALLY. C PALATE – use Breck Feeder/ cup Refer pt to: SPEECH THERAPIST. LOGAN BAR/ BOW – it decrease tension at suture line. FEEDING DEVICE – C CLIP – use dropper. place to RIGHT SIDE LYING SEATED at car seat – to facilitate the entry of food from stomach to duodenum • • OLIVE-SHAPE MASS VISCIBLE PERISTALTIC MOVEMENT – usually from L to R of the abdomen – w/c can lead to DHN LAB DATA : Ba Swallow – (+) “string sign” NSg Dx : Altered Nutrition Fluid Vol Deficit Fld and E imbalance Nutrition Surgery – FREDET-RAMSTEDT or PYLOROMYOTOMY PI : – incision at pyloric sphincter CELIAC DISEASE GLUTEN –INDUCED ENETEROPATHY .
abdominal distention and pellet-like or ribbon-like stool. oats. sausage.there will be SEVERE DHN LAB DATA : Nsg Dx : PI : Diagnostic Test : GLUTEN CHALLENGE – 3-4 mos – give gluten rich food And if there is malabsorption. macaroni. therefore (+) CDses Altered Nutrition Dietary Modification : AVOID GLTUEN RICH FOOD : ALLOWED : Rice. rice. soy beans Barley. cereals. hotdog HIRSCHPRUNG’S DISEASE MP : (AGANGLIONIC MEGACOLON) Absence of parasympathetic nerve fibers in a portion of a colon dilation. wheat Commercially prepared cakes are made of wheat – AVOID Ok or allowed: if pt say “I will prepare a homemade cake” AVOID : spaghetti. corn. luncheon meat.MP : Genetic predisposition Life-time disorder Intolerance to GLUTEN OUTSTANDING S/S : Malabsorption Syndrome-crisis Abdl Enlargement – this can be triggered by INFECTION & Fld and E imbalance Anorexia Anemia . Patient – meconium ileus & constipation – HALLMARK SIGN LAB DATA : BA Enema Nsg Dx : Diet : Tx : Meds : Altered Ellimination High Fiber Increase fluids Give Enema Laxative Surgery – SOAVE Surgery – resection with end to end pull through INTUSSUCEPTION MP : There is telescoping of a part of a colon which leads to inflammation and edema .
High Fiber wonder drugs – steroid surgery TRACHEOESOPHAGEAL FISTULA (TEF) MP : Failure of the esophagus to develop as a continous process Types : AF1 AF2 AF3 AF4 AF5 AF6 esophagus NOT connected w/ abdomen/stomach esophagus attached to trachea (when pt eat. it goes to the lungs) stomach connects w/ trachea stomach & esophagus connected stomach.) Coughing. eso and trachea are connected separated properly Atresia – “narrowing” Fistula – connection S/S : Excessive Drooling – danger in aspiration (avoid glucose water as initial feeding – use sterile H2O instead. Chocking Cyanosis LAB DATA : Nsg Dx : PI : Lateral Neck Xray – to check the esophagus Risk for Aspiration Safety Airway Keep child NPO – just give pacifier Surgery (if feeding OK – use sterile H2o instead NOT GLUCOSE) Tx : TIPS FOR GASTRO – PEDIA w/c of the ff signs if manifested by a child post tonsillectomy needs to be reported – FREQUENT SWALLOWING. Flds.S/S : “sausage-shape mass” Abdominal distention “Dance sign” – the R lower portion of the colon becomes empty Vomiting : BILE-STAINED Constipation LAB DATA : Ba Enema: if for DIAGNOSTIC : it outlines the area involve if for THERAPEUTIC : it reduces intussuception by means of hydrostatic pressure Nsg Dx : Diet : Tx : Constipation Altered Elimination Inc. .
w/c of the ff is expected in a child suffering from celiac dses – intolerance to gluten PEPTIC ULCER RF : Stress Smoking Salicylates or NSAIDS Helicobacter Pylori Zollinger-Ellison Syndrome (gastinoma) – tumor of the stomach – GASTRIC RF : MP : same Weakened Mucosa Common in Female Below 65 Inc risk for CA due to increase HCL acid ESOPHAGEAL same DUODENAL Excessive HCL Acid Common in Male 65 yo & above OUSTANDING S/S: PAIN – aching. a child who has had several episodes of diarrhea is likely to develop – metabolic acidosis. a common manifestation of pyloric stenosis is – visible peristaltic wave. the priority nsg dx for a pt w/ rotavirus infection is – diarrhea. the most appropriate feeding device for a child post cleft palate – paper cup. burning. fried. stenosis. w/c of the ff actions of the nurse is important – weighing pt daily for wt loss. in relation to dx of p. the priority nsg care for a child on NPO is – offer a pacifier regularly. SUCRALFATE . RANITIDINE . raw fruits and vegetables .severe bleeding – “shock” 2-3hrs after meal Nightime Pain relieved by eating HEMATEMESIS (vomiting of blood) Also related as hyperacidity LAB DATA : GASTRIC Analysis (diamox blue – urine) Gastroscopy BA Swallow HgB Hct Nsg Dx : PI : PAIN Relief of Pain Meds : ANTACIDS: Maalox – it NEUTRALIZE HCL Acid.it DECREASE HCL Acid. w/c of the ff will the nurse expect to observe in a child who loss fluid due to diarrhea – flushed dry skin.it COATS the GIT NO ASPIRIN Diet : BLAND DIET – NO SPICY. gnawing PAIN – 30mins – 1hr post meal PAIN at daytime Pain relieved by vomiting .
banana & pineapple) GASTRIC SURGERY VAGOTOMY PARTIAL GATRECTOMY – Billroth I (BI) and Billroth II (BII) TOATAL GASTRECTOMY BI – gastrodoudenostmy – duodenum and stomach BII – gastrojejunostomy – stomach and jejunum COMPLICATIONS: PERNICIOUS ANEMIA – due to decrease INTRINSIC FACTOR w/c came from stomach. DUMPING SYNDROME (occur usually for 10-12 mos post surgery) – due to rapid emptying of the stomach and stimulation of gastro-colic reflex GASTRO-COLIC REFLEX – is usually due to increase CHO INTAKE in the diet .NO PANCAKE. – Specifically @ recto-sigmoid colon at DIVERTICULUM S/S : DIARRHEA FEVER (15-20x/day) bloody mucoid (+) same diarrhea & constipation (+) LLQ Inflam of small & large intestine same 3-4x/day (+) RLQ CRAMPY ABDL PAIN LLQ (Rigidity (REPORT ASAP) –sign of colon rupture) LAB DATA: BA ENEMA Colonoscopy Stool Exam PAIN Altere Elimination: Diarrhea Nsg Dx : PI : Relieve Pain Meds: Steroids . NO UPRIGHT SITTING AFTER MEALS S/S OF Dumping Syndrome : Diarrhea Diaphoresis Dizziness/drowsiness Management: NO FLUIDS after meals – instead in between meals DIET: High Fats – because it delays the emptying of the stomach LOW CHO Lie down – after eating INFLAMMATORY BOWEL CONDITION ULCERATIVE COLITIS DIVERTICULITIS CROHN’S DSES (Regional Enteritis) RF : With familial Predisposition Common in those LOW FIBER Diet Related to Genetics Smoking as Protective Effect Common in Aging Common in Obsessive-Compulsive Or Stress Related or to “perfectionist” MP : Inflammation @ large Intestine Inflam @ L Intes.(EXCEPT: avocado.
emerge up to pelvic area with ice pack at head to prevent dizziness STOOL SOFTENER SURGERY PANCREATITIS RF AUTODESTRUCTION OR AUTODIGESTION of the pancreas #1 Alcoholism #2 autoimmune High Fat Diet Biliary Dses PAIN @ peri-umbilical area or epigastric that radiates to peri-umbilical area SS . Bag : 48hrs or 3x a wk BEST TIME TO DO COLOSTOMY CARE – at home.5 cm Diameter : 5cm When to empty colostomy: when 1/3 – ½ full (EMPTY DO NOT CHANGE) When to change C. while in the bathroom STOP colostomy irrigation if patient (+) ABDOMINAL CRAMPS HEMORRHOIDS MP RF PREGNANCY PROLONGED STANDING PORTAL HPN – hepatic enceph and liver cirrhosis Varicosities of the ANAL SPINCHTER GRADE I II III IV Small Area Large Area – reduces spontaneously Entire Area – manual reduction Entire Area – irreducible TYPES INTERNAL H – above the spinchter EXTERNAL H – below the spinchter S/S Pruritus Pain Bleeding Sigmoidoscopy Proctoscopy P Exam Altered Elimination LAB DATA Nsg Dx PI Diet : High Fiber Avoid Spicy PAIN – use SITZ BATH (48 degree C – temp of H2o) .Anticholinergic Antidiarrheals Antispasmodic DIET : Low Fiber and Low Residue – for Ulcerative and Chron’s Diverticulosis – High Fiber/residue – allowed: vegetables Low residue – (no vegetables) SURGERY : Colostomy – irrigate Ileostomy – no need for irrigation Characteristic of N Colostomy – REDDISH or PINKISH EDEMATOUS MOIST N elevation from skin: 2.
COUGHING.GREY TURNER SIGN – pain w/ bluish discoloration at flank area. bladder RF Fat Female Fertile Forty flatulence same S/S R UQ Pain radiating to R shoulder or R Scapula – usually precipitated by FATTY INTAKE GI S/S – NAV diarrhea and Jaundice URINE: dark colored STOOL : “clay-colored” or grayish – alcoholic stool LAB DATA Increase AMYLASE. CHOLE – 4 small incision. FATS Increase Liver Fnx test USG PAIN Relief of Pain meds : DEMEROL diet: LOW FAT surgery : 1) LAP. body flds .complication: “Pneumonia” – report rusty-colored sputum hx teaching: TURNING. DEEP BREATHING Nsg Dx PI HEPATITIS MP TYPES A Infectious Fecal-oral Inflammation of the Liver B SERUM C D POST TRANSFUSION Non A & B E DELTA HEPA Post Hepa B ENTERICALLY-TRANSMITTED Fecal-oral bld. WBC. CULLEN’S SIGN – pain w/ bluish discoloration @ umbilicus NAUSEA & VOMITING SHOCK – as complication LAB DATA Nsg Dx PI Elevated Serum Amylase (N56-190 u/L that normalize in 2 wks) PAIN Relieve PAIN Meds: DEMEROL – DRUG OF CHOICE AVOID MORPHINE – it causes more pain bec it will causes spasm to the spinchter of oddi DIET LOW FAT AVOID alcohol CHOLELITHIASIS Combine or usually come together in a pt CHOLECYSTITIS Stone in gall bladder Inflammation of the G. CO2 insufflation 2-3 days after – discharge pt and back to ADL 1 WK after – pt can lift weight 2) CHOLECYSTECTOMY – R SUBCOASTAL .
POST ICTERIC . c. LAB DATA pt prone to bleeding. Alcohol and Drugs Vitamins & Minerals Signs and symptoms a.2-6 wks 6wks-6mos 70-80 days 6wks-6mos (Hepa A & B Combination STAGES OF HEPA B PRE-ICTERIC .1-2 days : S/S NAVDA – NO jaundice yet. malnutrition – no cho metabolize edema – due to fld retention (bec of dec albumin) Flds & e imbalance Increase Liver Funx Test Liver Biopsy Nsg Dx Risk for Injury Fld & E imbalance Fld Vol Excess Altered Nutrition SAFETY HOW? PI Meds: Diuretics – due to fld retention ANTIHPN – due to portal HPN Clotting factors : Coagulants – give Vit K (to avoid bleeding) LOW CHON or CHON to Tolerance Or High Biologic Value CHON – good quality CHON (eg poultry products) Diet : . Diet : High Calorie Low Fat Isolation : A & E – Enteric B. b.2-4 mos s/s subside Increase Liver Funx Test (Inc AST/ ALT) Hepa A – Inc HaV Hepa B – HbsAg Infection Alt Skin Integrity Body Image Disturbance Tx for Infection a. D – Universal Lab data Nsg Dx PI COMPLICATION Liver Cirrhosis LIVER CIRRHOSIS . immunoglubolin.2-4 wks w/ jaundice.scarring of liver tissues TYPES LAENNE’S Due to alcoholism BILIARY CARDIAC POST NECROTIC due to Hepatitis Due to biliary Disorder due to CHF S/S – are related to 3 FUNXs of the LIVER MANUFACTURES : METABOLIZES: STORES : bile. Meds : HEPATOPROTECTORS DIURETICS b. & clotting factors CHO. d. ICTERIC . Fats. CHON. C.
ABDL GIRTH & REPSIRATION effective if : Pt decrease wt of 5 lbs and decrease or N RR c. w/c shld the nurse prioritize – Administration of Antibiotics. ASCITIS – accumulation of fluids at the abdomen s/s : wt gain Increase abdl girth – “I cannot button my pants anymore” (fluids) management: abdominal paracentesis – aspiration of fluids from the peritoneum . Lactulose b.effective if (-) hematemesis TIPS GASTRO – ADULT A pt w/ appendicitis was admitted. which of the ff indicates a ruptured appendix – absence of pain.complication: chance for infection & shock pt preparation: #1 instruct pt to void. . of ALL the ff written orders. #2 position: sitting the evaluate the WEIGHT. BLEEDING ESOPHAGEAL VARICES – DUE TO portal HPN Lab data Sengstaken Blakemore Tube – 48 hrs inflated. SURGERY : Liver Transplant COMPLICATIONS: a. HEPATIC EBCEPHALOPATHY – accumulation of ammonia – toxic to brain s/s: PERSONALITY CHANGES DECREASE LOC or irritability/ restlessness . scissors at bed side (Balloon Tamponade) .common s/e : DIARRHEA DRUG OF CHOICE : Neomycin.facilitate excretion of ammonia by acidifying the colon . w/c statement if made by a pt w/ cirrhosis is a risk factor for having the disease – “I drink 2 glasses of alcohol /day”.
how long have you noticed the white in your eyes turns yellow. the priority nsg care post common bile duct exploration – preventing hypostatic PNA. ff subtotal gastrectomy. the nurse shld expect gastric drainage for the 1st 12 hrs to be – reddish brown. pay attention to the ff: . w/c question during nsg assessment would confirm the Dx of L Cirrhosis . the priority nsg dx for a pt w/ Hepa B – altered Nutrition the priority nsg dx for for pt w/ acute pancreatitis – Altered nutrition less than body requirements NEUROLOGY DECORTICATE – abnormal FLEXION DECEREBRATE – abnormal EXTENSION Opistotonous – “back arching” GENERAL CONSIDERATION When assessing the neurological system.
fatal and could even lead to death CONCUSSION – jarring of the brain. MONITOR THE PT . Assess for presence of URTI – could be sign of Meningitis.DECORTICATE RIGIDITY DECEREBRATE RIGIDITY NO RESPONSE 4 3 2 1 – – - OPEN SPONTANEOUSLY OPENS TO VERBAL COMMAND OPEN TO PAIN 2 NO RESPONSE 1 SCORE OF 3 SCORE OF 15 Score of 8 : : : ORIENTED CONFUSED INCOMPREHENSIBLE NO RESPONSE NO response (DEAD) – Doctor will the one to pronounce pt is awake 50-50. mother wallet Associate mother’s time w/ child activity (children has NO DEFINITE TIME) Ex. Check for bowel and bladder funx – indicates neurological maturity 15-18 months – START BOWEL TRAINING 2 yo – start bladder training b. DECEREBRATE – more serious . CONTUSSION – more severe. Your mom will be back after you have eaten your lunch. #1 LEVEL OF CONSCIOUSNESS #2 BEHAVIOR #3 REFLEX When assessing MUSCULO SYSTEM: #1 Range of Motion #2 Joint Stiffness #3 POSTURES PEDIATRIC CONSIDERATION a.abnormal extension w/c indicates damage to brain stem GLASGOW COMA SCALE EYE OPENING (4) VERBAL RESPONSE (5) 5– 4– MOTOR (6) 6 5 4 3 2 1 – – – OBEYS COMMAND LOCALIZES PAIN WITHDRAWS FROM PAIN INAPPROPRIATE 3 . Assess child for S/S of anxiety bed wetting nail biting (N up to 4 yo) head banging excessive thumb sucking e. Assess for their habits “security blankets” – ex. Otitis Media d. “na-alog” w/c could lead to s/s of LOC in 24-48 hrs DECORTICATE – abnormal flexion which indicates damage to the cortex s/s : #1 Decrease LOC #2 widening pulse pressure (increase systolic BUT diastole is N) #3 Convulsion & seizures ABOVE ARE S/S OF INCREASE ICP. Hemophilus influenza. Stuff toys. c.
OLFACTORY : SENSORY : smell Abnoxious smell Anosmia – no smell Perfume II . Prognosis : complete recovery in 3 months Treatment : splint and cast for 3 mos – leads to nerve .50% chance Daughter as Carrier – 25% chance DMD Erb Duchenne’s Paralysis (EDP) Klumpke Palsy (KP) Related to Birth Injuries affecting the BRACHIAL PLEXUS – nerves at axilla portion HEREDITARY EDP – upper plexus KP . FACIAL : SENSORY : and sense of taste @ anterior 2/3 of the tongue Facial Expression MOTOR : VIII. OPTIC : SIGHT – snellen’s chart – 20/20 usually by age 3-6 yo OCCULOMOTOR TROCHLEAR ABDUCENS Eye movement . observe for balance IX. VI. IV. X.motor movement of shoulder muscle – TONGUE MOVEMENT DUCHENE’S MUSCULAR DYSTROPHY (DMD) X –linked RECESSIVE (only mother transmit to SON) (-) Father Mother (+ carrier) Son . ACOUSTIC or VESTIBULOCOCHLEAR . GLOSSOPHARYNGEAL VAGUS SENSORY MOTOR – Posterior Taste 1/3 Of The Tongue . TRIGEMINAL : SENSORY : responsible for FACIAL SENSATION (to check.stand erect.lower plexus w/c leads to paralysis. XII.swallowing and gag reflex XI. SPINAL ACCESSORY HYPOGLOSSAL . use cotton & needle and run across the cheek) AND MOTOR : ability of pt to chew Reflex: CORNEAL REFLEX – (+) if both eyes can blink VII. III. close eyes.7 and BELOW : pt is COMA CRANIAL NERVES I.6 cardinal direction of gaze (if abnormal look for DIPLOPIA) V.Sense of hearing and balance TEST : ROMBERG’S TEST .
200 ml) – rich in glucose .characterized by ATRESIA of and it protrudes to Foramen magnum Foramen of Luschka & Magendie SIDE NOTES: FLOW OF CSF (N amt : 100.X-linked RECESSIVE DIRORDER MP characterized by progressive muscle atrophy w/c apparent in male at the age of 3 a) GOWER’S SIGN – inability to stand up . d. mothers. b. Leg braces Meds : Anticunvulsants.duck-like gait c) impaired mobility d) difficulty in running and climbing COMPLICATIONs LAB DATA Nsg Dx Respiratory Paralysis – for young children Cardio-Resp. Arrest . Muscle Relaxants Prepare child for SURGERY – release of TENDON OF ACHILLES – to promote mobility Refer child to : PT – for gross motor movement – walking OT . HYDROCEPHALUS NOT A DISEASE but a manifestation of an existing disorder Related to ARNOLD CHIARI MALFORMATION DANDY WALKER SYNDROME there is ELONGATION of the BRAIN STEM or Medulla . Supportive . Female Sibling.leg brace. c. Aunt. Cause S/S Unknown Exaggerated Reflexes Protrusion of the tongue or tongue thrusting Early pattern of hand dominance Back Arching Scissors-gait Neurological Assessment PExam Risk for Injury Impaired Physical Mobility SAFETY a.use arms to brace the body b) WADDLING GAIT .for adolescent Muscle Biopsy PExam Ineffective Breathing Pattern Impaired Physical Mobility AIRWAY (keep TRACHEO at bedside) regeneration S/S PI TX a.Permanent. Fix (non-progressive) neuromuscular disorder characterized by abnormal muscle movement. crutches Refer parents to geneticist Target: Mothers or FEMALES – bec they are the source of transmission Ex. female members of the family – (bec transmission: X linked recessive) CEREBRAL PALSY .for fine motor – to open a bottle of soft drinks LAB DATA Nsg Dx PI b.
meninges and portion of spinal nerves LAB DATA Amniocetesis – test for ALFA FETO CHON – if INCREASE – Neural Tube Defect If DECREASE – Down Syndrome CT SCAN PExam NSG DX Risk for Injury .From Lateral Ventricle it goes to Foramen of Munroe then to 3rd Ventricle then to Aqueduct of Sylvius then it moves to F. Meningomyelocele – CSF. S/S OF HYDROCEPHALUS PROJECTILE VOMITING IRRITABILITY ENLARGED HEAD – N Head Circumference : 33-35 cm (chest circum: 31-35 cm) SEPARATION OF SKULL BONES SEIZURES SUNKEN EYES – Can Progress To Bossing Sign MACEWEN SIGN – crack pot sound upon knocking the head CT Scan MRI PExam – focus on head circumference (tape measure – at bedside to measure H Circumference) Risk for Injury SAFETY Semi Fowler’s – to prevent increase in ICP Diuretics Anticonvulsants Ventriculo-Peritoneal Shunt – progressive procedures (AS CHILD AGE PROGRESSES. of Luschka and Magendie going to 4th Ventricle then it goes back to subarachnoid spaces of brain. the surgery is revised) LAB DATA NSG DX PI Position Meds Surgery SPINA BIFIDA TYPES – failure of a PORTION of spinal cord to fuse SB OCULTA NO SAC W/ DIMPLE or TUFT OF HAIR W/ SAC SB CYSTICA SUB TYPES: Meningocele – w/ sac that contains CSF and meninges.
Vomiting 4. decerebrate Nsg Dx PI Risk for injury To decrease ICP Head of Bed ELEVATED Evaluate Neuro Status – Glasgow AIRWAY Discharge Meds Instruction Anticonvulsants. Position: Prone or side lying (NEVER SUPINE). INITIAL: Behavioral Changes – irritability.PI Protect the sac a. . and Neisseria Meningitidis disorder S/S of MENINGISMUS Inflammation of meninges but WITHOUT infection Usually accompany w/ resp. Diuretics (mannitol – to dec amt of cerebral edema) Seizure precaution – DARKENED ROOM MENINGITIS Inflammation of meninges w/c could be related to the presence of bacteria esp the H. c. Steroids. Vital Signs Changes – widening pulse pressure DECREASE RR and PR INCREASE temperature 3. INC ICP + Kernig’s Sign – pain on extension of lower extremities + Brudzinkis .at bed side) Post Surgery Complication INCREASE ICP ICP above 15mmhg (N 0-10) Mild elevation : 11 – 20 Moderate : 21 . decrease LOC – drowsiness or pt becomes sleepy 2. Influenza. Wet sterile gauze to cover the skin. b. restlessness. DOUGHNUT ring SURGERY WITHIN 24-48 HRS COMPLICATION Bladder and Bowel Problem Paralysis of Lower Extremities Hydrocephalus (tape measure.30 Severe : 31 and above With the use of INTRAVENTRICULAR or SUBDURAL MONITORING DEVICE to monitor ICP RF Hydrocephalus Space Occupying Lessions Brain Tumor Trauma S/S 1. Monitor Abnormalities – decorticate.flexion of neck would lead to flexion of lower ext.
may cause hearing impairment . Bacterial Meningitis – respiratory of droplet precaution b..refer REYE’S SYNDROME Non inflammatory.enteric precaution MEDS Antibiotics to AUDIOLOGIST For Bacterial Meningitis . Viral Meningitis . non recurring but TOXIC ENCEPHALOPATY and HEPATOPATHY (CNS) (LIVER) RF TRIAD S/S Presence of Viral Infection Use of Aspirin Fever Impaired Liver Funx Impaired Consciousness w/c could lead to convulsion I II III IV V pt becomes lethargic confusion decorticate rigidity decerebrate rigidity seizure or coma STAGES LAB DATA Bleeding and Clotting Time Liver Biopsy Neurological Assessment Risk for Injury Altered Thought Process Altered Thermoregulation Impaired Physical Mobility Treatment – symptomatic – assess neuro status Bleeding – give Vit K AVOID ASPIRIN when there is VIRAL INFECTION Nsg DX PI CVA/ STROKE MP Decrease Oxygen to brain cells TYPES THROMBOSIS EMBOLISM HEMORRHAGE INFARCTION .sign of MENINGEAL IRRITATION LAB DATA Nsg Dx PI Lumbar Puncture CSF Analysis Infection Risk For Injury Safety Seizure Precaution Tx the Infection Type of Infcetion: a.
memory disturbances – WERNICK’S LANGUAGE AREA (choice of words.RF atherosclerosis hpn obesity smoking stress age/ gender SIGNS & SYMPTOMS: 1. b.pt can say right words – mgt: picture board and Receptive . SIGNS AND SYMPTOMS INDICATIVE OF COMPLICATIONS Hemianopsia Hemiphlegia Emotional Lability Aphasia loss of half of the visual field (eg. COMPLETE STROKE – there is FOCAL s/s if R side of Brain Affected – L Eye .inability to understand spoken words (Wernick’s area) mgt: talk to pt slowly Dysphagia LAB DATA Diagnostic Test instruct the pt to swallow twice to prevent aspiration Increase Cholesterol CT Scan MRI EEG Unilateral Neglect – inability to care half of the body Impaired Physical Mobility Risk for Injury Nsg DX . TIA – brief period of neurologic dysfunction that last less than 24 hrs (between episode. understanding . pt is N).above s/s could last 2-3 days c.RECEPTIVE APHASIA). paralysis of one side of the body. STROKE IN EVOLUTION – there s/s like: facial paralysis Muscle weakness .R Face – L Body if L Brain – R Eye – L face – R body 2. . •PARIETAL .DISORIENTATION – especially SPATIAL orientation. RELATED TO LOBES • • FRONTAL – if affected – PERSONALITY CHANGES opening). DEPENDS ON THE PROGRESSION a. Pt consumes half of the food at plate). •OCCIPITAL .VISUAL disturbances 3. “mood swing” Expressive – inability to find right words to say (damage to Brocka’s Area). – BROCA’S AREA (expressive aphasia – mouth TEMPORAL .
Diplopia and Ptosis – progresses to MASK-LIKE face which lead respiratory depression (descending paralysis – start at face – “NO LAB DATA Nsg Dx PI MEDS CSF – Increase CHON (to all neuromusco disorders) TENSILLON TEST – 5 mins same same Neostigmine – ATSO4 . depression which to telebabad”) S/S Muscle weakness w/c begins at therefore.due to under medication or lack of meds. in ACTH – MP Inflammation that leads to destruction of Peripheral Nerves 90% w/c leads to: ASCENDING GBS “neurotransmitter” DESCENDING GBS Mixed Type GBS ASCENDING GBS . .#1 Clumsiness that eventually lead to face muscle weakness & resp.antidote Avoid crowded areas : viral infection Ineffective Breathing Pattern (ALL) AIRWAY (tracheostomy – bed side) – ALL Steroids Refer to NEUROLOGIST.PI Position Meds SAFETY Semi-fowler’s Elevated Antihypertensive Diuretics Antilipimic Agents Anticonvulsants Thrombolytics – if (+) thrombus – to dissolve clots Low Na and Cholesterol Range of Motion Exercises Craniotomy Infratentorial Cranio – FLAT Supratentorial . NO gender related factor but could be related to viral infxn Reversible MG Common in Male and Female Early onset : 20-30 yo (Female) Early onset : above 50 yo (male) Deficiency in ACTH Receptor Sites – Or Def.due to over medication – overdose . PULMOLOGIST and PT MYASTHENIA GRAVIS COMPLICATIONS • • Myasthenia Crisis (MC) Cholinergic Crisis (CC) .Semi-fowler’s DIET Activity Surgery DISEASES OF NEUROMUSCULAR : Guillain Barre Syndrome (GBS) Myastenia Gravis (MG) Multiple Sclerosis (MS) Amyotrophic Lateral Sclerosis (ALS) GBS • • • Descending paralysis – start @ upper ext.
therefore generalized muscle weakness Eg. Genetically Transmitted: AUTOSOMAL DOMINANT – common in Male & Female More Pronounce is DYSPHAGIA The muscle weakness – will eventually lead to RESPIRATORY DEPRESSION LABDATA CSF – Increase CHON EMG – “contract and relax” – needle insertion Muscle biopsy Ineffective Breathing Pattern AIRWAY (tracheostomy) SUPPORTIVE Refer to Geneticist NSG DX PI SIDE NOTES: . “I know I will be eventually confined in the wheelchair s/s of generalized muscle weakness: FACIAL – diplopia Impaired Cerebellar Funx Ataxic Gait – “lasing” Impaired Sensation – NO HOT/COLD BATH Impaired Sensory Funx – impotence dyemlination LAB DATA #1 MRI – specific test for MS – it localizes the area of plaque formation or the area of #2 CT SCAN NSG DX DRUGS same with GBS & MG STEROIDS Anticonvulsants – dilantin Muscle relaxant – Baclofen Bladder Stimulants – Urecholine (bethanicol) AVOID : HOT COLD SHOWER Refer to PT: ROM Exercises HX TEACHINGS AMYOTHROPIC LATERAL SCLEROSIS (LON GAHRIG’S DISEASE) MP Destruction of Upper and Lower Motor Neurons.Signs and symptoms of above complication: MUSCLE WEAKNESS – in MC due to ACTH Deficiency while in CC due to or as adverse effect of the drug Treatment : TENSILLON – effective in MC – it INCREASE MUSCLE STRENGTH Effect in CC – it worsens muscle weakness once given – give ATSO4 NEOSTIGMINE – for MC as TREATMENT MULTIPLE SCLEROSIS Common among women – especially white There is destruction of MYELIN SHEET at CNS .
G6PD Dses – mother (+) trait NOT DSES and transmit to SON SPINAL CORD INJURY Destruction of S.TO KEEP THE BLADDER EMPTY. Color Blindness.Complete quadriphlegia Nsg Dx PI COMPLICATIONS OF SPINAL INJURY : AUTONOMIC DYSREFLXIA – due to full bladder and bowel s/s : #1 INITIAL : HPN #2 Diaphoresis #3 slight fever what to keep at bedside: CATHETER . b. therefore PARAPHLEGIA – bowel and bladder problem THORACIC CERVICAL c1 – c4 C5 – C8 LAB DATA Myelogram CT Scan Xray Risk for Injury Impaired Physical Mobility SAFETY a.paraphlegia + bowel and bladder problem . w/c comment made by a pt demonstrate that she understands the procedure – “I will wash my hair after the procedure”. Duchennes Muscular. .DSES A Recessive : A Dominant : Cystic Fibro. Immobilize the spine – side lying w/ pillows bet legs Surgery . surgery LUMBOSACRAL AREA – if affected. Sickle Cell. BEC IF FULL IT WILL TRIGGER THE ANS TIPS FOR NEURO • A 10 yo is to undergo EEG. Cord related to TRAUMA TYPES • • • • • PI CERVICAL THORACIC LUMBAR SACRAL COCCYGEAL SAFETY 8 – most serious – quadriphlegia 12 5 5 1 .incomplete or partial quadriphlegia .immobilize. ALS – either father or mother (+) for disease or trait X Link Recessive : Hemophilia. Apalstic/Fanconis – either or both parents are (+) for trait NOT Retinoblastoma.
w/ Myasthenia gravis. To achieve voiding. The PRIORITY NSG DX for pt w/ Myasthenic Crisis – Ineffective Breathing Pattern MUSCULO CLUBFOOT DEFORMITY MP Types Talipes Varus – “inversion” Talipes Valgus – “eversion” Talipes Equinus – “tiptoe” LAB DATA Nsg Dx PI PE Xray Impaired Physical Mobility Promote Mobility Congenital Foot twisted out of place . w/c of the ff statements confirm the dx – “I have difficulty in swallowing”. When taking care of pt w/ C4 Spinal Injury.• • • • • • A pt w/ tumor of the frontal lobe will most likely manifest – difficulty in concentrating. Sclerosis has urinary incontinence. While interviewing a pt. w/c equipment shld the nurse keep @ the b. w/c nsg care shld the nurse give – establishing regular voiding sked. the PRIORITY Nsg Dx – Unilateral Neglect. A male pt w/ CVA is observed by the nurse to have consumed half of his meal.side – Urinary Catheterization Set. A pt w/ M.
head of femur or both Extra Gluteal Fold – at affected side.for 2-3 mos #3 Hip Spica Cast LAST RESORT NO ADDUCTION OF LEGS! Nsg Dx PI FRACTURES MP TYPES Break in the continuity of the bone Open (compound) – bone tears the skin – therefore open: risk for infection CLOSE – skin intact • • • • • • • S/S AVULSION – tear in the tendon COMMINUTED . Ortoloni’s Sign – (+) Click Trendelenburg Sign or Pelvic Dropping – Alli’s Sign or Galleazi’s Sign – LAB DATA when child stand in one foot toward the affected side. then there is change in length shortening of the affected leg PExam Barlow’s Manuever – press leg downward – (+) click Ortolani’s – abduct leg sideward – (+) click Impaired Physical Mobility #1 Double or triple diaper – to keep legs in abducted position.#1 MANUAL MANIPULATION #2 SEREAL CASTING – every 1-2 wks til position normalizes #3 DENNIS BROWN SPLINT – 2-3 months CAST : assess for s/s of neurological damage: REPORT Capillary refill – if more than 3 sec.fragmented COMPRESSED – crushed IMPACTED – driven to each other DEPRESSED – pressed SPIRAL – goes around the bone GREENSTICK – incomplete #1 Deformity #2 Pain #3 Edema . #2 PAVLIK Harness . EDEMA Skin Color/ nailbed CONGENITAL HIP DISLOCATION MP S/S Maldevelopment of the Hips – that involves the acetabulum.
correctible OUSTANDING S/S Uneven Hemline.when both legs need to moved past the level of the crutches swing to – when both legs need to be moved AT THE LEVEL OF THE CRUTHES going upstairs – unaffected then crutch (goodleg – crutch – bad) going down – crutch then bad leg – then good leg SCOLIOSIS MP RF Lateral Deviation of the Spine STRUCTURAL – non correctible FUNCTIONAL . Uneven waistline. b.check skin color – capillary refill time .adolesence a. swing through . Casting – check for edema – elevate the affected areas. . Uneven shoulder (+) Rib Hump Prominent Iliac Crest Bend Over test – instruct to touch the toes and note for rib hump Xray Impaired Physical Mobility . 3 point gait .child Body Image Disturbance .#4 CREPITUS – sound created when two bone surface rob each other NSG DX PI Impaired Physical Mobility MOBILITY – immobilize the fx a. .indicated if 1 leg is allowed partial wt bearing and the other one is N. 4 point gait – indicated for partial wt bearing. Splinting.CRUTCH WALKING 2 point gait – indicated if both lower extremities has partial wt bearing. After cast. To decrease curvature – wear BOSTON or MILWAUKEE Brace – for 23 hrs/day except bathing b.check for presence of blood stained c. SURGERY – HARRINGTON ROD .LUQUE Avoid : Bending Jumping Rope Playing Tennis Trampoline Brisk Walking Swimming Cheer Leading LAB DATA Nsg Dx TX HX Teaching Allowed: OSTEOPOROSIS/ HUNGRY BONE .
spinnach .brisk walking MEDS : Ca Supplement .alendronate Fosomax – SIT UPRIGHT AFTER ARTHRITIS RHEUMATOID Common Affected Part MP Chronic. . systemic inflammation of connective tissues Synovial joints and joints of Upper extremities FEMALE Upper Extremities GOUTY MALE Lower Extremities OSTEOARTHRITIS MALE/FEMALE wt bearing joint S/S PAIN Inflammation Morning Stifness Stages of Rheumatoid A.bicycle reading .sardines ACTIVITY : Partial Weight Bearing (NO SWIMMING) – jumping rope .MP RF Loss of Bone Density #1 smoking AGING IMMOBILITY MENOPAUSE – decrease Estrogen Secondary to Existing Condition – as secondary Hyperparathyroidism PAIN Dowager’s Hump Short Stature Progressive Decrease in Height Decrease in Calcium Bone Densinometry Bone Scan Xray SAFETY S/S LAB DATA Nsg Dx How? DIET : High Ca especially 4 those with – OSTEOPOROSIS .seafoods .
Antiinflammatory STREROIDS c.with major compromise of funx STAGE 4 . STAGE 1 – no Disability STAGE 2 – with Interference To ADL STAGE 3 . MEDS : ASA . exercise: ROM SWAN NECK DEFORMITY GOUTY ARTHRITIS MP S/S Metabolic disorder of purine w/c leads to deposition or uric acid at joints site: THE GREAT BIG TOE (+) PAIN – usually aggravated by pressure (+) Inflammation above s/s affects the LOWER EXTREMITIES LAB DATA NSG DX PI Increase Uric Acid PAIN Impaired Physical Mobility Relief of PAIN Meds : Allupurinol. Probenecid Diet : Low Purine/ Purine Restricted: AVOID : Organ Meats SEAFOODS Alcohol ALLOWED: Cheese (EXCEPT fermented and Aged) Increase ORAL Fluid Intake OSTEOARTHRITIS A degenerative joint disease that involves the weight bearing joints – elbows & knees S/S PAIN – NO inflammation Bouchard’s Nodes (distal) Heberdene’s Node (proximal) LAB DATA xRAY Nsg Dx PI PAIN Impaired Physical Mobility Weight Control Hot or Cold Compress Health Teaching . Warm Bath. b.incapacitation ULNAR DRIFT LAB DATA Nsg Dx PI Decrease HgB Increase ESR PAIN Impaired Physical Mobility Relief of Pain a.
ASA Trunk Assistive Device (cane) SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) Autoimmune multi system dses characterized by inflammation of connective tissues JOINT CARDIOVASCULAR CNS OUTSTANDING S/S LAB DATA Nsg Dx : : : (+) pain. treat available s/s Steroids TX Drugs TRACTION PRINCIPLES T – rapeze bar R – equires free hanging weights A – nalgesic C – iculation monitoring T – emperature monitoring I . a pt on buck’s traction of the R femur ask the nurse how he can possibly move around. (+) s/s of dec LOC. .nfection prevention O – utput and input monitoring N – utrition S – kin Assessment TIPS FOR MUSCULO the priority nsg care for the pt w/ bucks extension traction shld be – ensure that the traction applied to the affected leg is always attached to the weight. What can the nurse advise the pt – you can hold on to the trapeze bar while moving. (+) chest pain. it would be necessary for the nurse to intervene if – the pt feet are pressed against the foot board. a pt is using CRUTCHES for the first time. Headache (also present in pt in PROCAINAMIDE TOXICITY) BUTTERFLY RASH Increase ESR PAIN Altered Tissue Perfusion Risk For Injury Symptomatic/ Supportive – meaning. pt in russel’s traction is being taken cared of by the nurse. w/c action reflects a need for further instruction – the pt bears his/her wt with his/her axial. Irritability. (+) morning stiffness.
w/c of the ff needs to be reported – extra gluteal folds. post spinal fusion –ROBAXIN –is given for w/c of the ff purpose muscle spasm. when assessing an infant.to decrease a child has hip spica cast upon discharge. w/c statement of the father indicates further instruction – “ I will hold on to the bar bet his legs to help move him” INTEGUMENTARY SYSTEM Burn – triage : face and perineum (priority) BURNS Traumatic injury to the skin brought about by : FIRE CHEMICALS PROLONGED EXPOSURE TO SUN ELECTRICAL CURRENT HOT H2O CLASSSIFICATION: . w/c of the ff can possibly indicate the presence of abnormality in an adolescent – uneven hemline – scoliosis. .
Ca. Vit C) FIRST 24HRS – SHOCK 72Hrs .INFECTION Complication Pt Preparation :Bed Craddle Fever dog ticks LYME’S DISEASE Rocky Mountain caused by BORRELIA BURGDORFERI (deer ticks) Dermacentor/ Variabilis – .According to Damage PARTIAL THICKNESS – FIRST DEGREE EPIDERMIS Pain Redness Eg sunburn 2ND DEGREE EPIDERMIS & PART OF DERMIS Redness Blister Formation pain FULL THICKNESS THIRD DEGREE SUB Q FATS MUSCLES LEATHERY APPEARANCE NO Pain 4TH DEGREE SUB Q FATS MUSCLES & BONES CHARRED APPEARANCE No Pain MINOR PARTIAL TICKNESS FULL THICKNESS less than 15% NONE MODERATE 15-25% <10% MAJOR 25% >10% RULE OF 9 – CHECK NOTE day 9 page115 BURN TRIAGE Priority : Burns of FACE PERIMEUM UPPER & LOWER EXT Burn related to Child Abuse Chemical – Fire THINK: R escue A larm C onfine the Fire E xtinguish the Fire PRINCIPLES OF NSG CARE FOR BURN PTS: B – reathing – Airway U – rine output monitoring R – esuscitation of Fluids N – utrition S – ilvadene Ointment DIET DAT (High CHON.
Chills.3-30 days or Dermacentor Andersori (wood) 2-3 wks s/s : Fever.which can lead to paralysis TX PI Avoid wooded area – “have you been to the woods?” Vaccination Use long sleeve Remove ticks w/ twizers – upward straight motion Chloramphenicol Tetracycline Meds DERMATITIS DIAPER (contact) Peak patients S/S : During infancy – 9-12 mos Due to prolonged exposure to urine. soap & excreta ATOPIC ECZEMA (adult) Cause : Hereditary Prone to asthmatic : RASH RASH + scaling. Musculoskeletal and CNS . Crusting Pruritus or itching Viscicles Management: Hydrate the skin w/ cold compress Meds: Benadryl (antihistamine) ROSEOLA Exanthem Causative Agent INC PERIOD RUBEOLA MEASLES Measle Virus 10 -20 days RUBELLA GERMAN MEASLES Rubella Virus 14 -21 days Herpez Virus Unknown s/s RASH FEVER and RASH Begins w/ face & downwards Face & downwards Non Pruritic Rose pink – begins w/ trunk . Pain. Rashes Generalized rashes RASHES: Bull’s Eye Rash or Rounder Rings At moist body parts Complications Cardio.
Period T Pallidum 10-13 wks GONORRHEA N Gonorrhea 2-7 days Zoster HERPEZ Simplex Vericella Zoster Virus Herpes Simplex Viruz Genital H Abdominal Oral Herpez Steroids 2-12 days vesicle Around the mouth Inner thigh Buttocks Genitals Acyclovir Cervical Ca – complication of Herpez Annual pap smear TRICHOMONIASIS Caused by TRICHOMONAS Vaginalis Both are STDs Charac of discharge : Greenish/ Yellowish With FOUL ODOR Inc Period Druf pf Choice 4 – 20 days Flagyl MONILIASIS/CANDIDIASIS Albicans WHITISH-CHEESELIKE discharge 2 – 5 days Amphotericin .Progressing outward With KOPLICK’S SPOTS 3 C’s : Coryza Cough Conjuctivitis MANAGEMENT: (to all types) Bed rest Antibiotics Antipyretic + same SYPHYLLIS C Agent I.
Upon assessment.TIPS A nurse admits 8yo brought by her mother.Overuse. w/c of the ff is the priority nsg dx – PAIN. w/c of the ff is the priority – administration of fluis. the nurse finds rounded rings of rash. and Abuse Smoking : RACE : Lung. This is indicative of – HERPEZ A pt with CA of the cervix was admitted with the ff data: w/c one indicates a possible risk factor – previous tx for herpes. Underuse. This is indicative of – lyme’s dses. w/c of the ff indicates effective tx of gonorrhea – (-) purulent discharge. a pt is diagnosed w/ herpes zoster. A pt tells the nurse that he notice small blisters on his private parts. w/c of the ff is indicative of CHLAMYDIASIS – burning on urination CANCER Cause RF Unknown Theory of USE . During the immediate 24hrs pot burn.Cervix and Prostrate Whites – Testes Nulliparity – breast having baby after 35 yo Multiparity – cervix High Fat and Low Fiber – CA of Colon Spicy – Ca of Prostrate PARITY : DIET : . Bladder and Laryngeal or Oral CA Jewish – Breast Blacks .
spongy testes or lump (N – smooth unequal) TIPS FOR CANCER w/c nsg dx is a priority for a pt undergoing chemotherapy – SOCIAL ISOLATION. nocturia change in bowel habits painless enlargement of lymph nodes crytorchidism. w/c of the ff is an appropriate diet for pt undergoing chemo – bland diet.anually b. well balance C aution pt on s/s E xercise R est COMMON S/S LARYNX LUNGS STOMACH BREAST OVARIAN CERVICAL PROSTRATE COLON Hodgkin’s Dses TESTICULAR change in VOICE or Hoarseness changing cough or smoker’s cough (productive) dyspepsia a lump or a discharge complains feeling of fullness or indigestion “bleeding” elevated acid phosphatase. when undergoing chemotheraphy.target are high school Female: a. Testicular Self Exam – mothly – begins age 16 yo. Breast self exam – beginning age 20 – monthly c. w/c solution is used for mouth care – HYDROGEN PEROXIDE. A sess Body Image N tuition/diet : high CHON.Raw – Ca of Stomach LABDATA Screening Exams Male: a. Pap smear – at age of 18 (if sexually active) . Mamography – baseline : 35-40 yo : AFTER 40 yo – once every 2years After age 50 – annually BOTH MALE AND FEMALE Nsg Dx Digital Rectal Exam Sigmoidoscopy STOOL FOR OCCULT BLD : : 40 and above – ANUALLY ANUALLY after age 50yo Annually after age 50 yo Knowledge deficit HOPELESSNESS Initial If pt is TERMINALLY ILL If pt has some wishes or Unfulfilled needS : Powerlessness Nsg Care Principles : C hemotherapy – target cells : those rapidly dividing cells. pt w/ CA of esophagus will manifest – DYSPHAGIA . the most common sign of Breast Ca is in – upper outer quadrant.
where shld the nurse put the pt on early alcoholic withdrawal – well-lighted room near nurses station TIPS FOR OB-GYNE A Mother Is Crying Besides her baby. A pt w/ bipolar episodes is ready for discharge when – she can comply with units activities. w/c of the ff situations reflects an increase in self-esteem of an abuse child . The nurse would suspect that the child is a victim of abuse if he – keeps quiet while an IV is inserted. she said “I feel so sorry I couldn’t hold her” – let her stroke the baby. the nurse notes mirror image in the fetal monitor – this could be related to FETAL HEAD COMPRESSION. 6wks pregnant woman ask the nurse about the signs of pregnancy – w/c one is expected at this time – frequent urination. A nurse shld assess the pt w/ ALZEIMER’S DSES for possible change in – orientation.TIPS FOR PSYCHE A pt w/ chronic depression is to undergo ECT. . the purpose is to – relieve the symptoms of depression.when he ask the nurse for a plastic cup to drink. which of the ff is related to trauma – ABRUPTIO PLACENTA. the initial care plan for a pt with Anorexia Nervosa would require the pt to – remain in public place 1 hour after meals.
A nurse is caring for a woman in first stage of labor. the appropriate room mate for an 8yo girl w/ leukemia is – 6 yo with hemophilia. she is timing the duration of contraction – she is correct when she times it from the beginning of one contraction to the end of same contraction TIPS PEDIA w/c of the ff is expected by 6mos of age – sits w/ minimal support. in a 3yo child – w/c of the ff shld the nurse assess during admission – special words used for objects and routines. w/c of the ff is appropriate way of administering pre-op meds to 4 yo child – ask the child where she would like the injecvtion to be given . the most appropriate toy for 18 mos old child – carriage w/ a doll.
Paralysis of Lower .
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