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Atrial and ventricular rate are 60/100 .

Atrial Fibrilation : P Wave no definitive.
Se admin anticoagulante, cardioversion as prescribed.

Premature Ventricular contraction

Notify Physician,Adm O2 as prescribed , Lidocaine .

Ventricvular tachycardia
RCP,Cardioversion ,antidysrritmicos.

Ventricular Fibrilation:

Fluter Ventricular :



Ventricular Fibrilation

Atrial fibrillation

CPR . before desfibrilation.

360 joules
Continuar CPR, Intubate,,star
Epinefrine img IV Push every
3/5 min
Sodio bicarbonate ,acidosis.

Valium IV
Digoxin withheld for 48/h
prior procedure.
Voltage : 25-360 joules

Head injury :
skull fracture, contusion,laceration, hematoma.
Evaluar/implementation: level conciencias, neurological assessment, monitor
level conciencia, elevate the head 30 grado ,prevent complication inmobility,
manage increased intracranial pressure and edema cerebral(glucocorticoides).

Increased intracranial pressure: Glasgow scale, level conciencia ,confusion

,restlessness (early signs)
Papillary changes ( early signs)
Vital signs
Elevated head 30-45 grado to promote venous drainage from brain
Avoid neck flexion and head rotation
Reduce environment stimuli
Medication: osmotic diuretic, cortiscosteroides therapy ,antiseizure .

Spinal cordon injure

Loss of motor and sensory function below level of injure.
Flaccid paralysis, complete loss of all sensation, decreased pulse ,postural
hypotension, circulatory problems ,alte termoregulation.

Celiac Disease : intestinal malabsortion, that lead to malnutrition ,diarrhea,

failure to thrive. nurse consideration: gluten free diet( no wheat, oats ,rye,
barley(centeno, cebada).no trigo
Renal failure : high calorie, low protein diet, as allowed by kidney function.

Cystic Fibrosis : absence of pancreatic enzymes lead to malabsortion of fat

and fat-soluble vitamin,weight loss, infection and lung disease lead to increased
need for calories and protein.nurse consideration : pancreatic enzyme
replacement, before or with meals, hight protein diet, hight calories diet .

Hernia Hiatal: heartburn,regurgitation, dyspepsias.small frequen feedings,do

not lie downs for at least 1 h after meals, elevate head of bed 4-8 inches whwn
sleeping,do not eat before going to bed to prevent reflux of food.
Pyloric Stenosis :vomiting proyectil infants,irritability,infant always hungry
,epigastric fullness,infant fails to gain weight,peristaltic wave.

Duodenal ulcer

Gastric ulcer

Gastric secretion


Normal to hyposecretion


2-3 h after meals,

nighttime ,often in early
sleeping hour
Food intake relieve
Less likely

1 hour after meals or

Relieved by vomiting
Ingestion of food does
not health
More likely


Eat : 3 meals per day, small frecuent feeding , avoid milk and cream

Antiacid( malox) 1 h before or after meals.
Histamine receptor site antag ( cimetidine,ranitidine),take with meals
Anticolinergicos,give: 30 min before meals
Cytoprotective agent (carafate ) ,1 h before meals
Proton pump ( prilosec).
Teach preventive measures for dumping syndrome ; restrict fluids with
meals, drink 1 hour ac or 1 hour pc,eat semi-recumbent position ,lie down 20-30
min after meals,eat small, frecuent meals,low carbohydrates and fiber diet,
Hirschsprungs Disease: ganglionic disease of the intestinal tract ,inadequate
motility causes mechanical obstruction of intestine .
Child : failure to gain weight ,delayed growth,constipation alternating with

Surgery : enema,low fiber hight calories,hight protein diet ,oral antibiotic

measure abdominal girth at level umbilicus. postoperative care: colostomy is
Cholecystitis : severe pain in upper right quadrant of abdomen radiating to
back and right shoulder .
Intolerance fatty food, indisgestion, nauseas ,vomiting, flatulence
,eructation,elevated tempereature, leukocytosis diaqphoresis ,dark urine ,clay
colored stools.
Rest, IV Fluid, NG suction, low fat liquid powdered supplement high in
protein ,carbohydrates, stirred into skinh milk ,avoid : fried food,pork,cheese
Pancreatitis :abdominal pain,epigastrio ( en forma cinturon ) vomiting 48 h
after heavy meals or alcohol ingestion. hypotension, acute renal failure
,ecchymosis in flank around umbilicus.( signs Cullen).
History alcoholism/bacterial or viral infection/trauma/complication of mumps,
medication: tiazide, corticosteroid, oral contracerptive.
Implementation: NPO,Gastric descompression, analgesic,Demerol,respiratory
care,cough and deep breath q2h,semi-fowler position,monitoriar shock and
hiperglicemia,TPN,Avoid : alcohol, caffeine,low fat ,bland diet ,small frecuenbt
Crohn disease : inflammatory condition of any area of large or small intestine,
usually ileum and ascending colon.usual age : 20-30 and 50-80.fatty stool
(esteatorrea),frecuent,diarrhea less severe ,rectal bleeding ocacional,fistula and
anorectal fissure common,fever
Ulcerative colitis :inflammatory condition of the colon characterized by erode
areas of the mucous membrane and tissue beneath it.age: young adult to
middle age 30-50,fatty stool absent,diarrhea 10-20 liquid stool pr day,rectal
bleeding common,blodd ,pus ,mucus in stool ,fistula and anorectal fissure
rare.fever .
Nurse Consideration ( ambas enfermedades); high protein,high calories ,low
fat and low fiber diet
Reye syndrome ; acute metabolic encephalopathy of childhood thet causes
hepatic dysfunction ,causes: use ASA, with viral illness.
Fever/increased ICP, /decreseased level concienciousness, coma/decresed
hepatic function,diagnosed liver biopsy.

Preoperative care :
Toddler : separation,tech parent to expect regression .
Preschooler: with model of equipment ,encourage expression of
School ager: loss control, explain procedure in simple terms.
Adolescent . loss independence ,alte body imagen.involve procedure and
therapies .

Suctioning :
hyperoxigenar before ,during and after succioning.100% O2 for 3 min or 3 deep
Explain procedure.
Semi/fowler position.
Lubricate catheter with sterile saline .
Advance catheter as far as possible or until clien cought.
Apply suction and withdraw catheter with rotating motion no more than 10
Repeat procedure after patient has rested
Endotraqueal and traqueostomy tube suctioned ,then mounth is suctioned.

Trachesostomy care :
Procedure :
Perfom every 8 h and as needed.
Explain procedure
Hyperoxigenate or deep breath
Suction trachestomy tube
Remove old dressings
Open sterile trachestomy care kit

Put on sterile gloves

Remove inner cannula
Clean with hydrogen peroxide
Rinse with sterile water ,dry
Reinsert into outer cannula
Clean stoma site with hydrogen peroxide,sterile water ,then dry.
Change ties as needed ,old ties must remain in place until new ties are
secured ,tie on side of neck,allowing 2 finger to be inserted under tie.
Apply new sterile dressing ,do not cut gauze pads.
Documentar .

Chest Tube :
Intrapleural drainage system .
Nurse care:
Fill water seal chamber with sterile water to the level specified by
If suction is to be used ,fill the suction control chamber with sterile water to the
20 cm level.
Encourage change position frecuently
Drainage system must be maintained below the level of insertion without kinks
in tubing
Chest tube are clamped only momentarily to check for air leaks and to change
the drainage apparatus.
Observed for fluctuations of fluid in water seal chamber ,stop fluctuating:
lung re-expand/tubing is obstructed/loop hangs below rest of tubing/suctioning
is no working.
Nasogastric Tube :
types: Levin/salem sump/sengstaken Blakemore /keofeed/dobhoff/cantor
/miller-Abbbott /Harris .
Insertion Leving

Measure distance from tip of nose to earlobe plus distance from earlobe to
bottom of xifhoid
Mark distance,tube with tape and lubricate end of tube with water soluble jelly
Insert tube through the nose to stomach
Offer sips of water and advance the tube gently
Observed for respiratory
Nurse Care:
Check residual before intermitente feeding and 4 h with continuous
feeding ,Hold feeding if more then 100 ml.
Instill 15-30 ml ,before and after each dose medication and each tube feeding,
after check residual and PH.
Change bag every 24-72 h
Elevated head 30 grados and after feeding .

Enema :
Procedure :
Explain procedure
Position Sims
Use tepid solution
Hold irrigation set at 12-18 inches for high enema, for slow enema 3 inches
Insert tube no more then 3-4 inches adult, 2-3 inches for child and 1-1.5 inches
Ask patient to retain solution 5-10 min
No administer in abdominal pain/nauseas/vomiting .
Urinary Cateher:
Male :
Explain procedure
Expose urinary meatus
Claeanse glands, with sterile povidone iodine ,wabs in circular motion.

Hold penis perpendicular ,insert catheter intro urethra 6-7 inches.

Resplace the foreskin
Inflate balloon
Gently apply traction to the catheter until resistence is felt
Female :
Assemble equipment
Place : dorsal recumbent position or Sims position
Drape patient with sterile drapes using sterile technique
Apply steriles gloves
Lubricar catheter
Separate labia with thumb and forefinger and wipe from de meatus/sterile
Insert cateher 2-3 inches intro urethra, after urine to flow
Inflate balloon
Gently apply traction to the catheter
Tape drainage tubing to patient thigh .